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LIPPINCOTT'S 

HOME   MANUALS 

EDITED  BY 
BENJAMIN  R.  ANDREWS,  Ph.D. 

ASSISTANT  PROFESSOR  OF  HOUSEHOLD    ECONOMICS,    TEACHERS   COLLEGE, 
COLUMBIA  UNIVERSITY 


HOME  AND  COMMUNITY  HYGIENE 

Bt  jean  BROADHURST,  Ph.D. 

ASSISTANT   PROFESSOR   OF   BIOLOGY,   TEACHERS   COLLEGE, 
COLUMBIA    UNIVERSITY 


LIPPINCOTT'S 

HOME  MANUALS 

Edited  by  BENJAMIN  R.  ANDREWS,  Ph.D. 

TEACHERS  COLLEGE,  COLUMBIA  UNIVEB8ITY 

CLOTHING  FOR  WOMEN 

By  LAURA  I.  BALDT,  A.M. 

TEACHEBS  COLLEGE,   COLtTMBIA  TJNTVEBSITT 

454  pages,   7  colored  plates,  262  illustrations  in  text 

SUCCESSFUL  CANNING  AND  PRESERVING 

By  OLA  POWELL 

DEPABTMENT  OP  AGBICULTDBE,  WASHINGTON,  D.  C. 

370  pages,  4  colored  plates,  153    illustrations  in  text 

HOME  AND  COMMUNITY  HYGIENE 

By  jean  BROADHURST,  Ph.D. 

TEACHEBS  COLLEGE,  COLUMBIA  UNIVEBSITy 

428  pages,  1  colored  plate,    118   illustrations  in  text 

THE  BUSINESS  OF  THE  HOUSEHOLD 
By  C.  W.  TABER 

ATITHOR  OF  TABEB's  DIETETIC  CHARTS, 
NUBSES'     MEDICAL    DICTIONARY,   ETC. 

438  pages.     Illustrated. 
HOUSFWIFERY      ^^  ^  ^^^  BALDERSTON,  A.M. 

XIKJ  \J  OJJ  »  Y  ±±  J_/XV  J.  TEACHERS    COLLEGE,    COLUMBIA    UNIVEBSITy 

450  pages,  1  colored  plate,  illustrated  in  text 

MILLINERY       in  PBEPABATION 

By  EVELYN  SMITH  TOBEY,  B.S. 

TEACHERS    COLLEGE,    COLUMBIA    UNIVEBSITY 


LIPPINCOTT'S 

FAMILY  LIFE  SERIES 

Edited  by  BENJAMIN  R.  ANDREWS,  Ph.D. 

TEACHEBS  COLLEGE,  COLUMBIA  UNIVEBSITY 

CLOTHING 

CHOICE      CARE      COST 
By  MARY  SCHENCK  WOOLMAN,  B.S. 

290  pages.     Illustrated. 

SUCCESSFUL  FAMILY  LIFE  ON  THE 
MODERATE  INCOME 

247  pages  By  MARY  HINMAN  ABEL 


LippixcoTT's  Home  Manuals 

EDITED  BY  BENJAMIN  R.  ANDREWS,  Ph.D. 

Teachers  College,  Columbia  University 


HOME  AND 
COMMUNITY  HYGIENE 

A  TEXT-BOOK  OF  PERSONAL 
AND  PUBLIC  HEALTH 

BY 

JEAN  BROADHURST,  Ph.D. 

ASSISTANT  PROFESSOR  OF  BIOLOGY,  TEACHERS  COLLEGE 
COLUMBIA  LNIVERSITY 

118  ILLUSTRATIONS 


PHILADELPHIA  AND  LONDON 
J.  B.  LIPPINCOTT  COMPANY 


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COPYRIGHT,    1 918,    BY    J.    B.    LIPPINCOTT   COMPANY 


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Electrotyped  and  Printed  by  J.  B.  Lippincott  Company 
The  Washingtori  Square  Press,  Philadelphia,  U.  S.  A. 


TO  THE  NURSES,  TEACHERS 
AND  MOTHERS  OF  AMERICA 


PREFACE 

This  book  is  so  planned  that  anyone  reading  first  the  two 
introductory  chapters  (I  and  II)  may  read  the  remaining  chapters 
in  any  preferred  sequence.  Household  Economics  students  as  well 
as  housekeepers  may  prefer  to  begin  with  Chapter  XIII,  The  Home, 
passing  at  any  desired  point  to  related  chapters.  For  example,  in- 
terest in  food  may  suggest  next  the  chapter  on  food,  or  on  milk; 
household  pets  may  lead  to  the  chapter  on  transfer  of  disease  or 
cleaning  methods  to  the  chapter  on  disinfection. 

Nurses  will  find  many  possible  starting  points,  though  school 
nurses  as  well  as  teachers  may  choose  Chapter  XV,  on  the  school, 
from  which  point  drinking  fountains  may  lead  to  the  chapter  on 
water,  school  epidemics  to  the  chapter  on  prevention  of  disease,  or 
the  ventilation  problem  to  the  chapter  on  air  and  ventilation,  etc. 

This  flexible  plan  is  further  made  possible  by  the  addition  of  a 
glossary  containing  simple  definitions  to  which  the  reader  is  re- 
ferred by  a  (G)  placed  after  any  technical  term  the  first  time  it 
occurs  in  each  chapter.  This  glossary  and  the  introductory  char- 
acter of  the  first  two  chapters  insures  its  readability  to  any  really 
interested  student  in  normal  schools  and  colleges.  This  book  has 
been  made  as  brief  as  the  varied  chapter  content  would  allow,  much 
of  the  material  ordinarily  included  being  condensed  into  tables. 
Although  cross-references  usually  indicate  the  related  material,  the 
index  should  be  consulted  freely.  Advanced  students  should  con- 
tinue to  use  the  more  advanced  texts,  some  of  which  are  most  valu- 
able and  comprehensive.    (See  reference  lisl^  in  Appendiij.) 

The  problems  are  meant  as  suggestions  only.  They  are  not 
meant  as  recitation  or  review  questions,  but  to  indicate  possible  lines 
of  departure  for  individual  work,  or  to  lead  to  the  immediate  or 
practical  application  of  the  contained  subject-matter.  An  effort 
has  been  made  to  secure  variety  in  these  problems ;  very  often,  how- 
ever, a  problem  in  one  chapter  can,  with  the  modification  of  a 
word  or  two,  be  applied  to  another. 

This  book  will  fail  in  its  purpose  if  it  does  not  lead  to  increased 
practical  application  of  the  hygienic  measures  implied  and  recom- 
mended— both  in  the  home  and  in  the  community. 

J.  B. 

July,  1918. 

vii 


ACKNOWLEDGMENTS 

Foe  helpful  suggestions  or  criticism  acknowledgment  is  due 
Miss  Caroline  E.  Stackpole,  Teachers  College;  Professor  C.-E.  A. 
Winslow,  Yale  Medical  School;  Dean  V.  A.  Moore,  Cornell  Uni- 
versity; Miss  Elizabeth  P.  Sheppard,  State  Normal  School, 
Trenton,  IST.  J.;  and  Miss  Mary  Wheeler,  Illinois  Training 
School,  Chicago.  To  the  following  students  who  "stood  by"  in 
the  hurried  preparation  of  this  volume:  Miss  Helen  C.  Stevenson, 
Miss  Katherine  S.  Ink,  Miss  Mae  Wells,  Miss  Anne  Dix,  and 
especially  to  Miss  Mary  E.  Turnbull,  who  helped  also  with  the 
index,  an  appreciative  acknowledgment  is  made. 

Eecognition  is  also  due  to  Dr.  Chapin  and  the  John  Wiley 
Publishing  Company  for  permission  to  reprint  the  long  extract 
credited  to  Dr.  Chapin  in  Chapter  IX,  and  to  Dr.  Lusk  and  the 
Saunders  Publishing  Company  to  reprint  the  rules  of  Saving  and 
Safety  in  Chapter  III. 

For  illustrative  material  acknowledgment  of  original  photo- 
graphs is  rendered  to  Dr.  C.  B.  Hoover  for  the  sprinkling  filter 
(Frontispiece),  to  Dr.  F.  L.  Eector  for  Fig.  32,  to  the  Spencer 
Lens  Company  for  Fig.  1,  and  to  Dr.  Carroll  Gr.  Bull  for  Figs.  50, 
51  and  102.  Three  plates  from  Moore's  B'ovine  Tuberculosis  were 
loaned  by  the  Macmillan  Company,  Figs.  93,  95  and  96;  one  from 
Ritchie's  Primer  oi  Sanitation  by  the  World  Publishing  Company, 
Fig.  35;  and  one  from  Giltner's  Microbiology  by  John  Wiley  Co., 
Fig.  13. 

The  Northwestern  Steel  and  Iron  Works,  E'au  Claire,  Wis- 
consin, allowed  the  use  of  Fig.  18,  and  the  Heinz  Company  of  Fig. 
19.  Permission  from  the  authors  concerned  was  given  for  Fig.  2, 
from  Powell's  Successful  Canning  and  Preserving;  Figs.  4,  46,  57, 
58,  60,  and  61  from  Emerson's  Chemical  Diagnosis;  Figs.  56  and 
59  from  Steele,  International  Clinics;  Fig.  42,  from  Ross's  The 
Reduction  of  Domestic  Flies;  Figs.  55a  and  101  from  Thomas  and 
Ivy's  Applied  Immunology;  and  Fig.  94  from  Wilson's  Medical 
Diagnosis. 

Permission  to  reprint  the  chart  used  in  Fig.  14  was  granted 
by  the  Society  for  Improving  the  Condition  of  the  Poor.     Pro- 


X  ACKNOWLEDGMENTS 

fessor  Thomas  D.  Wood  gave  permission  to  reprint  the  charts  of 
the  American  Medical  Association,  Figs.  78,  81,  82,  83,  84,  86,  97, 
103,  105,  106,  111,  112,  and  113. 

The  Public  Health  Service  provided  the  original  for  Figs.  108, 
109,  and  115.  The  Children's  Bureau  gave  permission  to  reprint 
Figs.  91  and  92;  the  New  Jersey  State  Health  Department  for 
Fig.  98;  the  New  York  State  Health  Department  for  Fig.  49  (chart 
opposite  p.  186),  and  Figs.  39,  48,  54,  77,  104.  The  Horace  Mann 
School,  New  York  City,  gave  the  two  blanks  used  as  Fig.  85  and 
reprinted  on  p.  269.  To  the  Bureau  of  Animal  Industry  is  due 
credit  for  Figs.  26,  27,  and  45;  to  the  Department  of  Agri- 
culture for  Figs.  22  and  24;  and  to  Russell  and  Hastings  as  well 
as  Moore  and  Ward  of  the  Department  of  Agriculture  for  Fig.  20 ; 
to  the  Virginia  State  Health  Department  for  Fig.  37;  to  the 
Chicago  Department  of  Health  for  Fig.  90;  to  Hampton  Institute 
for  Fig.  44;  to  Geneva  Experiment  Station  for  Fig.  23;  and  to 
the  Department  of  Agriculture,  Cornell  University,  for  Fig.  25. 

Illustrations  have  been  redrawn  as  follows :  Fig.  3,  after  Nocht 
and  Mayer;  from  WinsloVs  Healthy  Living,  Figs.  6  and  116; 
from  Mansfield's  Histology  of  Medicinal  Plants,  Fig.  16;  from 
Whitaker,  Bureau  of  Animal  Industry,  Fig.  31;  from  Ritchie's 
Primer  of  Sanitation,  Fig.  29 ;  the  Health  News  of  New  York 
State,  Fig.  41;  Ogden's  Rural  Hygiene,  Figs.  '62  to  65  inclu- 
sive; Talbot's  House  Sanitation,  Fig.  70;  Raynes's  Domes- 
tic Sanitary  Engineering  and  Plumbing,  Figs.  71,  72,  and  73 ; 
Journal  of  Bacteriology,  Fig.  79;  Wilson's  Field  Sanitation,  Figs. 
99  and  100;  and  the  United  Kingdom  Temperance  and  General 
Provident  Institution,  Fig.  110. 

Figures  75  and  76  were  provided  by  Miss  I.  Tovey;  Fig.  40  by 
Mr.  G.  W.  Prall;  Figs.  53  and  89  by  Miss  0.  Pye;  Fig.  114  by 
Miss  E.  P.  Sheppard.  The  illustrations  which  were  redrawn,  and 
all  drawings  not  otherwise  credited,  were  made  by  Miss  Margery 
Stewart. 


INTRODUCTION 

The  cloak  of  mystery  which  was  once  wrapped  about  the  art  of 
medicine  has  to  a  considerable  extent  been  discarded.  The  physi- 
cian of  to-day  takes  botli  patient  and  public  into  his  confidence 
and  so  far  as  possible  secures  their  intelligent  aid  and  co-operation 
in  the  difficult  task  of  repairing  the  ravages  of  disease. 

If  this  is  desirable  in  the  domain  of  curative  medicine,  it  is 
even  more  important  in  the  prevention  of  disease.  The  principles 
of  personal  hygiene  and  public  sanitation  must  be  made  familiar 
to  the  individual  citizen  if  they  are  to  be  effectively  applied;  for 
only  by  hearty  and  informed  co-operation  can  the  possible  fruits 
of  public  health  be  garnered. 

The  science  which  teaches  us  how  to  preserve  health  lends 
itself  with  unusual  facility  to  popular  exposition.  Its  main  prin- 
ciples are  simple  and  few  in  number.  They  involve  on  the  one 
hand  broad  biologic  principles  which  appeal  strongly  to  all  who  are 
open  to  the  absorbing  interest  of  fundamental  scientific  laws ;  and 
on  the  other  hand  in  their  practical  applications  they  reveal  points 
of  contact  with  the  most  searching  problems  of  social  and  economic 
organization,  problems  of  housing,  of  industrial  hygiene,  of  in- 
comes and  hours  of  labor. 

It  is  no  wonder,  then,  that  courses  in  "  Hjygiene,"  "  Sanitary 
Science,"  "  Preventive  Medicine,"  and  "  Public  Health"  are  being 
given  with  increasing  frequency,  not  only  in  schools  of  medicine 
and  nursing  but  in  departments  of  home  economics,  in  engineering 
schools  and  academic  colleges.  Some  course  of  this  kind,  adapted 
to  the  special  needs  of  the  class  of  students  in  question,  should 
indeed  form  an  essential  and  required  part  of  every  system  of 
education,  from  the  elementary  school  to  the  university.  Yet 
strangely  enough  there  has  been  so  far  no  satisfactory  text  available 
for  courses  of  this  kind  to  be  given  to  mature  but  non-technical 
students.  Eosenau's  "  Preventive  Medicine  and  Hygiene"  is 
admirable  for  the  medical  school.  Sedgwjck's  ^^  Principles  of 
Sanitary  Science,"  Chapin's  "  Sources  and  Modes  of  Infection," 
Fisher  and  Fish's  "  How  to  Live"  are  invaluable  sources  of 
collateral  reading  on  special  phases  of  the  subject.     A  text-book 


Xii  INTRODUCTION 

which  covered  the  whole  field  of  disease  prevention  and  health 
conservation  in  an  elementary  but  authoritative  way  has,  however, 
been  much  needed.  This  need  Professor  Broadhurst  has  met  in  the 
present  volume. 

The  subject  has  been  approached  throughout  from  the  practical 
standpoint  of  the  home-maker.  Problems  of  sanitary  engineering 
and  health  administration  are  touched  upon  lightly,  but  suffi- 
ciently for  the  uses  of  the  average  citizen;  while  those  applications 
which  are  of  immediate  moment  in  the  household  are  dwelt  upon  in 
helpful  detail.  The  book  will,  therefore,  be  of  special  value  to 
the  student  of  household  administration  and  to  the  student  of 
nursing,  who  must  be  expert  in  this  art.  In  addition  to  filling 
the  need  of  a  text-book  in  schools  of  home  economics  and  nursing, 
it  should  have  a  wide  appeal  to  the  general  reader  who  desires 
familiarity  with  the  principles  which  govern  the  management  of 
the  living  machine  and  its  protection  against  harmful  environ- 
mental conditions. 

The  Great  War  has  emphasized,  as  never  before,  the  importance 
of  national  strength  and  national  efficiency ;  but  national  efficiency 
rests  upon  personal  health.  There  could  therefore  be  no  more 
timely  occasion  for  the  appearance  of  a  work  of  this  character; 
and  Professor  Broadhurst  has  performed  an  act  of  patriotic  service 
in  preparing  a  brief  and  popular  but  comprehensive  and  accurate 
statement  of  the  things  which  we  all  ought  to  know  in  order  to 
keep  fit  for  our  individual  and  collective  parts  in  the  world  con- 
flict and  in  the  reconstruction  that  is  to  come  after. 

C.-E.  A.  WiNSLOw 
Professor  of  Public  Health 
Yale  School  of  Medicine 


CONTENTS 


CHAPTER  PAGE 

I.    Bacteria  and  Other  Micro-organisms 1 

II.    The  Human  Mechanism  in  Relation  to  Health 12 

III.  Food 18 

IV.  Milk 62 

V.    Water 92 

VI.    Air  and  Ventilation 115 

VII.    Sewage  Disposal 149 

VIII.    Refuse  Disposal 162 

IX.    Transfer  of  Disease 168 

X.    Disinfection  and  Quarantine 183 

XI.    Treatment  and  Prevention  of  Disease 194 

XII.    Tests  for  Disease 213 

XIII.  The  Home 220 

XIV.  Summer  Camps _  _ 250 

XV.    Schools 255 

XVI.    Other  Community  Units  or  Relations 273 

XTVII.    Infant  Welfare 284 

XVIII.    Middle  Age 296 

XIX.    Tuberculosis 302 

XX.    Industrial  and  Occupational  Hygiene 315 

XXI.    Mental  Hygiene 320 

XXII.    Military  Hygiene 328 

XXIII.  Rural  and  Urban  Conditions 347 

XXIV.  Vital  Statistics 357 

XXV.    Health  Education 366 

XXVI.     Health  Administration 375 

Glossary 381 

Appendix 393 

General  References 399 

Index 405 


HOME  AND  COMMUNITY 
HYGIENE 

CHAPTER  I 
BACTERIA   AND    OTHER   MICRO-ORGANISMS 

So  much  is  said  and  written  nowadays  about  bacteria  that  prac- 
tically all  people  have  a  general  idea  that  they  are  very  tiny  organ- 
isms which  are  very  destructive  to  foods  and  xerj  injurious  to 
human  beings.  While  this  is  true,  it  is  but  part  of  the  truth,  as 
will  be  shown  later. 

We  popularly  use  the  word,  bacteria,  in  a  very  comprehensive 
sense,  to  include  both  microscopic  plants  and  animals  which  have 
these  destructive  powers.  Plants  and  animals,  as  we  ordinarily 
think  of  them,  differ  from  each  other  greatly  in  appearance  and  in 
structure.  One  of  the  mental  tests  applied  in  the  grading  of  chil- 
dren, and  for  the  isolation  of  the  feeble  minded,  includes  in  the 
questions  which  are  supposed  to  be  answered  by  any  normal  eight- 
year-old  child,  "  What  is  a  plant  ?  "  Mature  people  cannot  answer 
this  question  so  glibly.  They  know  so  many  plants  that  vary  from 
the  ordinary  garden  vegetable,  or  window  plant,  that  they  hesitate ; 
they  can't  describe  them  as  green,  because  they  know  that  mush- 
rooms are  plants,  but  are  not  green;  they  cannot  define  them  by 
saying  they  bear  flowers  or  seeds,  because  they  know  that  ferns  are 
plants  although  they  never  produce  flowers  or  seeds;  they  cannot 
define  all  plants  by  any  ordinary  character  of  color,  shape,  size,  etc., 
because  such  plants  as  the  bacteria  are  so  tiny  and  so  colorless  that 
they  cannot  be  seen  without  a  microscope  (Fig.  1),  and  then  best 
if  they  are  stained  with  a  colored  dye  or  special  stain.  The  types 
of  animals  vary  just  as  greatly ;  the  smallest  animals  are  just  as  un- 
like our  general  idea  of  animals  as  bacteria  are  unlike  our  general 
idea  of  plants.  These  small  plants  and  animals  are  really  very 
much  alike,  though  the  animals  are  usually  much  larger  than  bac- 
teria. Some  of  these  small  plants  resemble  the  animals  in  possess- 
ing free  swimming  movement  or  motility  (see  Fig.  2). 

1 


HOME  AND  COMMUNITY  HYGIENE 


General  Structure. 

the  aid  of  a  microscope- 
mals  micro-organisms. 


-Because  of  their  small  size — demanding 
-we  term  all  of  these  small  plants  and  ani- 
Most  of  these  small  animals  that  come 


Fig.  1. — Small  objects  such  as  bacteria  are  studied  through  a  compound  microscope. 
A  drop  of  material  containing  the  organisms  is  put  on  a  piece  of  glass,  and  placed  over  the 
opening  so  that  light  can  be  reflected  through  it  from  the  mirror  below.  This  microscope 
sfiows  two  lenses  of  different  magnifying  power,  any  one  of  which  can  be  turned  into 
position  directly  in  line  with  the  eyepiece. 

under  this  heading  are  called  protozoa,  the  first  or  simplest  forms  of 
animals  (protos,  first;  zoa,  animal).  Most  of  the  small  plants  be- 
long to  the  bacteria,  a  popular  group  name  for  several  kinds  of  tiny 
organisms,  in  which  are  included  bacilli   {singular  bacillus),  bac- 


BACTERIA  AND  OTHER  MICRO-ORGANISMS  3 

teria  {singular  bacterium),  cocci  {singular  coccus),  and  spirilla 
{singular  spirillum).  These  terms  are  based  mainly  on  shape,  the 
first  two  being  rod-shaped  (see  Figs.  60  and  102),  cocci  being 
globular  (see  Fig.  58),  and  spirilla,  spiral,  as  the  name  indicates. 
At  present  many  new  terms  are  being  discussed,  but  we  will  follow 


Fig.   2. — Bacteria  from  tomatoes  showing  numerous  little  extensions  called  flagella;  motility 
is  due  to  a  whip-lash  movement  of  these  flagella. 

the  popular  custom  of  referring  to  these  organisms  in  a  general  way 
as  bacteria ;  in  mentioning  the  exact  name,  e.g.,  typhoid  bacillus  or 
Bacillus  typhosus,  these  other  terms  may  occasionally  be  used. 
Different  kinds  of  organisms  may  have  compounds  of  such  names, 
e.g.,  meningo-coccus  causing  meningitis,  and  strepto-coccus  causing 
erysipelas,  sore  throat,  ear  abscesses,  etc.  The  protozoa  are  also 
subdivided  into  many  divisions  or  groups ;  as  examples  may  be  cited 


4 


HOME  AND  COMMUNITY  HYGIENE 


the  organisms  causing  Texas  fever  in  cattle  (Fig.  -io),  "  tsetse  fly  " 
disease  (Fig.  3),  and  tropical  dysentery-  (Fig.  4:)  and  malaria  (Fig. 
48)  in  man. 

Some  of  the  smaller  mold  plants,  such  as  those  making  the  blue 
spots  on  old  bread  or  leather  goods,  and  the  yeasts  of  bread, 
are    also    microscopic    organisms.     And    for   most    of   these    tiny 


Fig.  3. — Trypanosomes  transferred  by  the  "tsetse"  fly  in  an  African  disease  affecting  chiefly 
cattle  and  horses.    Similar  trypanosomes  cause  "sleeping  sickness"  in  man. 

animals,  molds,  ar.d  bacteria  the  layman  often  uses  the  iivord  micro- 
organisms. Bacteria  and  micro-organisms  are  often  loosely  used 
quite  interchangeably.  Microbes  and  germs  are  also  equivalent 
terms ;  and  some,  in  a  half  joking  way,  speak  of  them  as  bugs. 

What,  then,  are  these  micro-organisms?    They  are  tiny  plants 


Fig.  4. — An  intestinal  amoeba,  EntamcBba  histolytica.  Some  idea  of  the  relative  size 
of  such  protozoa  may  be  gained  by  noticing  the  bacteria  CE)  and  the  blood-corpuscles  (F) 
inside  this  amoeba.  As  these  small  animals  move  and  engulf  food  material  (such  as  bacteria) 
changes  occur  in  their  outlines  and  in  the  relative  size  of  the  clear  areas  shown  in  A. 


or  animals,  so  tiny  that  most  of  them  consist  of  but  a  single  cell  or 
unit  of  structure. 

Cellular  Structure  of  Plants  and  Animals. — Large  plants  and 
animals  consist  of  many  cells  or  units  of  structure.  A  cut  or  sec- 
tion through  the  skin  or  through  any  other  part  of  your  body 
would  show  under  the  microscope  dozens  or  hundreds  of  tiny  cells. 


BACTERIA  AND  OTHER  MICRO-ORGANISMS  5 

The  same  is  true  of  leaves,  stems,  or  roots  of  plants.  Below  is  a 
view  made  of  a  leaf  cut  across  from  top  to  bottom  (Fig.  5).  The 
cells  thus  revealed  differ  in  size  and  shape,  and  also  in  color  and 
contents.  These  differences  are  related  to  the  work  of  the  cell,  e.g., 
transparent  cells,  like  E,  transmit  light  to  the  inner  part  of  the 
leaf ;  hollow  tubes,  like  Y,  carry  water  through  the  stem  to  the  leaf. 
Size  of  Bacteria. — With  a  microscope  it  would  be  very  easy  to 
recognize  the  different  parts  of  ordinary  plants  and  animals  by  the 


Fig.  5. — Cross-section  of  a  leaf  presented  to  show  that  several  types  of  cells  are  present 
in  many-celled  plants  and  animals;  E,  covering  layer  or  epidermis;  P,  cells  manufacturing 
moat  of  the  sugar  and  starch;  V,  veins  carrying  water;  S,  protein-making  cells;  andG,  pair 
of  cells  regulating  the  passage  of  gases  and  water.  Figs.  3,  4,  and  51  show  whole  animals 
or  plants  where  each  plant  or  animal  consists  of  but  a  single  cell. 


kinds  of  cells  that  compose  them.  Adulteration  of  drugs  is  often 
proven  in  that  way  (Figs.  16  and  17).  But  the  smallest  plants  and 
animals  consist  of  but  one  cell  each,  and  these  single  cells  look  very 
much  alike — they  are  very  tiny  (3000  to  25,000  to  an  inch,  often). 
When  viewed  under  the  microscope,  which  makes  them  look  larger 
(1200  times  as  large  in  the  microscope  ordinarily  used  for  bac- 
teria), they  even  then  seem  but  tiny  dots  or  little  rods  about  the 


6  HOME  AND  COMMUNITY  HYGIENE 

size  of  the  period  and  the  letters  i  a-nd  1  used  on  this  page.  li 
yoU  could  divide  the  period  or  the  letter  i  into  1200  little  pieces, 
you  would  have  the  real  size  of  some  of  the  smaller  bacteria. 

Do  you  wonder,  then,  that  until  recently  people  never  saw  bac 
teria?  That  they  thought  the  lightning  soured  the  milk,  that  the 
"witches  killed  the  cows  or  that  Providence  caused  the  death  of  man  ? 

Action  of  Bacteria. — Objects  as  tiny  as  these  "  look  alike  "  to 
the  ordinary  observer.  But  even  those  which  seem  quite  alike  may 
behave  very  differently  when  placed  in  milk,  broth,  blood,  or  other 
tfood  materials  or  "media.''     Some  digest  certain  sugars  very 


•-'^••'v-^^^•■'j^S'■•>i>'^;."i■iSSi»S 


O.     .       1  A/        I  ftite-n  RCber      (tftef      filftep 

rtaL-nai  1)1  umber  t^MeeK  x"«Wecf(  j'-'weeK  4^''VYce/r 

Fig.  6. — Typhoid  bacteria  in  water  die  off  at  about  the  rate  indicated  by  the  above 
figures;  this  reduction  is  mainly  due  to  such  "natural  agents"  as  sunlight  and  oxygen. 
On  the  other  hand  multiplication  may  be  startlingly  rapid  when  conditions  for  growth 
are  favorable;  the  bulk  indicated  by  the  figure  on  the  left  may  result  from  one  bacterium  in 
much  less  than  four  weeks. 

rapidly ;  some  "  never  touch  them  " ;  some,  as  they  break  up  food 
materials,  accumulate  large  amounts  of  acid  or  alkali;  some  at- 
tack proteins  very  readily,  liquefying  or  dissolving  them.  The 
liquid  condition  of  spoiled  coffee  jelly  or  gelatin,  or  the  liquid  in- 
terior of  Camembert  cheese  is  due  to  organisms  having  this  liquefy- 
ing power.  These  different  powers  enable  them  to  grow  luxuriantly 
in  some  of  our  food  substances,  and  to  attack  even  live  plants  and 
live  animals. 

An  idea  of  the  shapes  of  micro-organisms  can  be  gained  from 
the  illustrations  mentioned,  but  more  important  is  their  action  on 
plant  and  animal  substances.     It  is  not  what  they  look  like,  but 


BACTERIA  AND  OTHER  MICRO-ORGANISMS 


Fig.  8. — Emptyglassdish,  Petri  dish,  used  in  cultivating  bacteria. 
Figs.  43  and  67  show  similar  Petri  dishes  with  bacteria  growing  on 
the  agar  in  the  lower  half  of  the  dish. 


Fig.  7. — A  very  old 
growth  of  diphtheria  on 
the  slant  surface  of  the 
agar  in  the  bottom  of 
the  test-tube.  (The 
cotton  plug  has  been 
pushed  down  to  the 
level  of  the  top  of  the 
tube.) 


c 


3- 


Fig.  9. — Needles  made  by  inserting  platinum  wire  in  glass  rods. 
These  enable  one  to  reach  the  material  in  the  bottom  of  test  tubes. 


HOME  AND  COMMUNITY  HYGIENE 


1 

CC 


y 


Fig.  10. — A  pipette 
used  in  measuring 
ortransferringlarge 
amounts  of  mate- 
rial. This  holds  one 
cubic  centinrvetre 
■X  c.c.)(G). 


what  they  do  that  interests  us  and  makes  us  want 
to  encourage  or  discourage  their  growth^  or  to  get 
rid  of  them  entirely. 

Beneficial  Micro-organisms. — Some  of  these 
tiny  organisms  are  very  useful  to  us.  Yeasts  and 
bacteria,  which  are  really  a  great  deal  alike,  them- 
selves use  up  a  little  of  the  food  substances  in 
bread,  in  milk,  and  in  soils;  but  nevertheless,  we 
derive  real  benefit  from  their  activities.  The  gas 
given  out  by  the  yeast  scattered  all  through  the 
bread  makes  the  bread  light;  the  acids  formed  by 
the  milk  bacteria  cause  it  to  sour,  and  coagulate, 
making  a  curd  useful  in  cheese  making;  the  soil 
organisms  add  large  amounts  of  necessary  minerals 
and  nitrates  to  the  soil. 

Another  important  use  of  these  organisms  is 
that  they  bring  about  decay  or  decomposition. 
Manure  and  other  excreted  material  are  very 
quickly  used  as  food  by  bacteria,  and  are  finally 
changed  to  harmless  inorganic  substances.  Our 
whole  problem  of  sewage  disposal  would  be  very 
different  if  bacteria  did  not  aid  in  that  way.  We 
do  fully  appreciate  their  aid  in  causing  the  decay 
of  falling  leaves,  dead  plants  and  dead  animals. 
Without  them,  eYerj  dead  tree  and  every  dead 
animal  would  retain  its  original  shape  and  bulk. 
Think  what  the  earth  would  look  like  if  none  of  the 
dead  animals  and  plants  ever  decayed !  Much  of 
the  material  in  plants  and  animals  as  it  disinte- 
grates goes  back  into  the  soil  and  forms  food  for 
other  plants ;  many  of  these  plants  in  turn  furnish 
animals  with  food.  How  long  would  it  take  to  use 
up  all  the  available  food  materials,  if  dead  plants 
and  animals  were  not  disintegrated  by  organisms 
and  so  used  over  again  as  food,  thus  helping  keep 
up  the  cycle  of  food  stuffs  in  nature  ? 

Harmful  Bacteria. — The  benefits  derived  from 
bacteria  are  emphasized  above  to  contradict  the 
usual  impression  that  bacteria  are  always  harm- 


BACTERIA  AND  OTHER  MICRO-ORGANISMS  9 

ful.  But  the  bacteria  we  shall  discuss  are  mainly  harmful  ones^ 
because  they  happen  to  destroy  or  injure  food  materials  {e.g., 
grains,  potatoes,  bread)  we  wish  to  conserve  and  use,  or  because 
they  prefer  to  grow  in  our  bodies,  using  up  the  food  materials 
we  need,  forming  poisonous  wastes,  or  actually  eating  or  dis- 
integrating our  body  tissue.  Examine  the  fester  that  forms  around 
a  splinter.  Part  of  the  white  "  matter "  in  the  fester  is  made 
of  white  corpuscles  from  the  blood  that  have  migrated  there  to  help 


Fig.   11. — Colonies  or  masses  of  bacteria  growing  on  agar  or  gelatin.    This  shows  bacteria 
from  the  intestine,  related  to  the  B.  coli  organisms  (Weigmann). 

destroy  the  invading  bacteria  carried  in  with  the  splinter;  part  is 
composed  of  broken-down  body  cells  and  mucous  excretions  from 
them;  and  still  another  part  is  made  up  of  the  bacteria  themselves. 
This  gives  a  fairly  good  idea  of  the  way  bacteria  grow  in  the  body 
and  injure  it.  Festers  and  sore  throats  are  very  localized  infec- 
tions; in  tuberculosis  (Fig.  94)  many  such  local  centres  of  growth 
may  be  distributed  throughout  the  body,  in  the  lymph-nodes  {G), 
joints  and  lungs.  Occasionally  large  areas  are  destroyed  as  the 
bacteria  increase  in  number.  Bacteria  often  multiply  very  rapidly 
(Fig.  6)  ;  a  doubling  of  the  number  every  twenty  or  thirty  seconds 
has  been  observed,  though  it  rarely  progresses  at  that  rate  very 
long. 

Spores. — When  conditions  become  unfavorable,  some  bacteria 
have  the  power  of  going  into  a  resting  stage,  in  which  their  cell 


10  HOME  AND  COMMUNITY  HYGIENE 

substance  is  less  sensitive  to  such  unfavorable  conditions.  A  differ- 
ence in  the  amount  of  oxygen,  the  accumulation  of  their  own  in- 
jurious wastes,  and  a  lack  of  food  or  water  are  some  of  the  conditions 
that  help  produce  this  resting  condition.  Commonly  the  cell  sub- 
stance gathers  in  a  concentrated  mass  called  a  spore  (Fig.  102). 
These  spores  are  very  resistant  to  such  conditions  as  heat ;  they  are 
usually  responsible  for  the  spoilage  of  canned  goods,  because  occa- 
sionally spores  survive  the  canning  process  and  later  begin  to  grow 
inside  the  can. 


Fig.   12. — A  common  organism  (soil,  water,  etc.)  showing  very  irregular  branching  colonies 

(Weigmann). 

Similar  adaptations  are  found  in  other  plants  as  well  as  bacteria. 
Winter  buds  can  stand  intense  cold,  and  seeds  can  usually  stand 
extremes  of  both  cold  and  heat — even  boiling. 

With  favorable  conditions  each  spore  makes  an  organism  like  the 
original  one.  This  multiplies,  dividing  into  two,  just  as  it  did 
before  spore  formation  occurred.  This  growing,  multiplying  stage  is 
called  the  vegetative  stage  in  contrast  to  the  resting  (or  spore)  stage. 

Cultivation  of  Bacteria. — Bacteria  are  cultivated  for  study  on 
solid  substances  like  gelatin,  and  in  such  liquids  as  milk,  and  meat 
broth  or  bouillon.  Agar,  an  extract  of  seaweed,  is  often  used,  as 
it  makes  a  firmer  substance  than  gelatin. 

These  substances  may  be  worked  with  in  test-tubes  (Fig.  7)  ; 
the  solid  substances  are  often  used  in  covered  glass  dishes,  called 
'''plates"  or  Petri  dishes  (Fig.  8).    The  food  used  in  these  dishes 


Bacteria  and  other  micro-organisms 


11 


and  tubes  is  heated  to  get  rid  of  any  other  organisms,  and  then  the 
desired  organisms  are  transferred  to  the  tubes  or  dishes  by 
"needles"  (Fig.  9),  slender  wires  which  are  inserted  in  glass 
handles  for  ease  in  manipulation.  When  workers  desire  to  take  out 
or  transfer  a  great  deal  of  material,  they  use  a  pipette  (Fig.  10). 
All  tools  are  sterilized  before  use  to  keep  them  free  from  undesired 
organisms.  Broth,  gelatin,  dishes,  etc.,  may  be  heated  in  a  steam 
boiler ;  needles  are  heated  red-hot  in  a  flame  each  time  before  using. 
The  tubes  are  usually  plugged  with  a  fairly  tight  roll  of  cotton. 
This  filters  any  air  passing  into  the  tube  and  keeps  out  the  bae- 


FiG.   13. — Other  colonies  with  irregular  outlines.     Colonies  like  those  shown  in  Figs.  67, 
75  and  76  are  more  common. 

teria  that  might  otherwise  get  in.  Bacteria  grown  in  the  ways  de- 
scribed above  are  commonly  spoken  of  as  cultures;  if  but  one  kind 
of  organisms  is  present  in  a  tube,  we  say  the  tube  contains  a  pure 
culture.  On  solid  substances  or  media  the  multiplication  of  these 
little  organisms  finally  produces  a  mass  that  is  visible  to  the  naked 
eye  (Fig.  11).  These  little  masses  are  spoken  of  as  colonies.  Such 
colonies  are  often  very  irregular  in  outline  (Figs.  13  and  13). 
Each  colony  presumably  started  from  one  single  organism,  and  rep- 
resents thousands  of  generations,  and  billions  of  individuals. 
See  Reference  List  at  end  of  Appendix. 


^  CHAPTEE  II 

THE  HUMAN  MECHANISM  IN  RELATION  TO 
HEALTH 

For  years  the  human  body  has  been  likened  to  an  engine,  a 
watch,  or  some  similar  mechanism.  And  old  as  the  comparison  is, 
it  is  difficult  to  find  a  better  one.  While  this  likeness  fails  if 
carried  too  far,  there  are  many  striking  points  of  similarity,  the 
most  striking  of  which  are  listed  below. 

1.  Both  Engine  and  Body  are  Complex  Structures. — Both 
the  engine  and  the  body  are  complicated  structures  composed  of 
many  different  specialized  parts— some  of  them  highly  specialized, 
such  as  the  human  eye  and  the  carbureter  in  a  motor  car. 

2.  Automatic  Control. — Some  of  the  parts  are  so  constructed 
as  to  make  possible  a  remarkable  degree  of  automatic  control ;  this 
is  well  illustrated  by  the  heat  regulatory  power  of  the  skin  and  the 
thermostat  device  used  in  heating  systems. 

3.  Foundation  Substances. — There  is  a  suggested  similarity 
in  the  fact  that  in  each  there  is  a  foundation  substance  modified  to 
form  various  parts  differing  not  only  in  use  but  in  appearance, 
elasticity,  hardness,  etc.  In  the  engine  this  foundation  substance, 
iron,  appears  in  such  different  forms  as  cast  iron,  wrought  iron,  and 
such  an  alloy  as  the  carbonized  iron  called  steel.  In  the  body  the 
foundation  substance  called  protoplasm  is  modified  into  many  dif- 
ferent types  of  tissue;  these  are  well  illustrated  by  such  familiar 
tissues  as  the  skin,  the  muscle  fibres  composing  lean  meat,  the 
glandular  tissue  making  the  bulk  of  liver  and  "  sweetbreads,"  and 
bone,  in  which  the  lime  deposits  wholly  change  the  appearance  and 
elasticity  of  the  protoplasmic  foundation  substance. 

4.  Fuel  Necessary. — The  likeness  most  often  emphasized  is 
with  regard  to  fuel.  Fuel  is  needed  by  the  body  and  by  the  engine ; 
and  both  must  have  suitable  kinds  of  fuel  and  enough  of  it.  This 
oldest  and  most  familiar  parallel  is,  strange  to  say,  the  one  least 
often  carried  to  its  proper  conclusion.  No  one  would  think  of  not 
choosing  carefully  the  type  of  fuel  to  be  supplied  to  an  engine;  this 

12 


HUMAN  MECHANISM  IN  RELATION  TO  HEALTH  13 

engine  needs  coal,  that  one  uses  oil,  and  another  must  have  natural 
gas,  or  perhaps,  gasoline.  But  with  our  own  bodies  we  carelessly 
assume  that  "  all  is  grist  that  comes  to  our  mill."  If  there  is  any 
selection,  it  is  too  often  based  on  cost  or  taste  rather  than  fuel  value ; 
"  anything  to  fill  them  up  "  is  a  vulgar  expression  of  this  same 
attitude.  An  engineer  selects  his  fuel  with  care,  refusing  to  buy 
coal  he  has  found  to  yield  large  amounts  of  such  waste  residue  as 
"  slag  "  or  clinkers ;  but  we  calmly  go  on  supplying  our  more  sensi- 
tive human  mechanisms  with  unsuitable  materials,  as  if  mere  bulk 
were  the  chief  or  sole  consideration. 

In  the  body  we  often  fail  to  relate  properly  the  amount  of  fuel 
to  the  amount  of  work  to  be  done.  Those  who  care  for  furnaces  or 
stoves  constantly  use  such  expressions  as  "need  but  a  low  fire," 
"  keep  piling  on  coal/'  and  "  running  the  furnace  for  all  it  is 
worth,  if  it  takes  a  ton  a  day."  But  we  are  just  beginning  to  con- 
sciously adapt  the  amount  and  kind  of  body  fuel  to  the  body  needs. 
We  may  unconsciously  eat  less  in  warm  weather,  but  it  is  quite  un- 
usual to  find  people  reducing  the  amount  on  a  day  when  the  physi- 
cal demands  are  going  to  be  less— -for  example,  on  stay-at-home 
holidays  and  Sundays.  The  sense  of  over-fullness  after  the  Sunday 
dinner  is  too  common  a  sensation  to  make  further  illustration  neces- 
sary. The  impossibility  of  doing  full  work  on  half  fuel  is  apparent 
to  anyone.  We  never  attempt  it  with  engines,  but  human  beings 
attempt  it  too  often.  A  clearer  recognition  of  the  impossibility  of 
continuing  to  yield  any  required  output  on  insufficient  food  is  neces- 
sary before  we  can  get  community  support  for  satisfactory  feeding 
of  the  submerged  part  of  our  population,  where  lack  of  fuel  is  evi- 
denced by  the  large  number  of  undersized,  anaemic  or  low-vitality 
individuals. 

5.  The  Need  of  Oxygen. — The  human  body  is  like  an  engine 
in  that  plenty  of  oxygen  must  be  provided  to  secure  complete  and 
economic  utilization  of  the  fuel.  Motor  car  engines  have  a  device 
for  the  proper  admixture  of  air  and  fuel ;  in  furnaces  the  air  spaces 
between  the  coal  are  constantly  filled  with  fresh  air  sucked  in  by 
the  draft ;  or  larger  amounts  of  fresh  air  may  be  secured  by  forcing 
or  pumping  air  with  its  necessary  element,  oxygen,  through  the  burn- 
ing bed  of  coal.  In  the  human  body  this  necessary  oxygen  is  ab- 
sorbed in  the  lungs  and  supplied  to  all  parts  of  the  body  by  the 
circulating  blood.     A  lack  in  red  corpuscles,  the  store  houses  of  oxy- 


14  HOME  AND  COMMUNITY  HYGIENE 

gen,  decreases  the  amount  that  can  be  absorbed  and  carried,  and 
therefore  the  amount  distributed  to  the  cells.  In  disease  {e.g., 
pneupionia)  the  lung  area  available  for  absorption  is  decreased. 
Providing  the  proper  amounts  of  oxygen  may,  therefore,  be  more 
of  a  problem  than  for  engines. 

6.  Disposal  of  Wastes. — A  sixth  likeness  is  the  necessity  for 
prompt  disposal  of  waste  substances.  The  ashes  must  be  removed, 
or  they  choke  off  the  draft  and  clog  the  fire.  In  the  human  body 
it  is  just  as  essential  that  wastes  must  be  eliminated  (though  the 
reasons  are  not  exactly  the  same).  Delayed  intestinal  elimination 
is  harmful,  because  the  blood  in  that  region  has  increased  oppor- 
tunity to  absorb  certain  poisonous  wastes  normally  formed  in  the  in- 
testine; these  poisons  irritate  and  poison  the  cells  to  which  they 
are  carried,  causing  the  headache,  etc.,  characteristic  of  constipation. 
In  constipation  there  is  another  danger  that  should  be  recognized. 
Bacteria  in  such  held-back  putrefying  masses  of  food  material  may 
more  easily  invade  the  intestinal  wall,  causing  serious  diseases,  e.g., 
appendicitis. 

7.  Variations  and  Limits  in  Activity. — A  seventh  likeness 
lies  in  the  fact  that  it  is  possible  to  speed  up  the  activities  of  the 
body  and  the  engine.  As  stated  before,  increased  output  demands  in- 
creased fuel,  increased  oxygen,  and  increased  elimination  of  waste. 
Too  much  may  be  demanded  in  both  cases.  In  machines  we  have 
more  definite  indications  when  the  limit  is  reached ;  there  is  a  posi- 
tive limit  to  the  number  of  revolutions  a  wheel  can  make ;  the  piston 
rod  breaks,  etc.  In  the  body  we  don't  have  the  same  marked  evi- 
dences as  warnings:  bones  don't  crack  as  piston  rods  do;  nerve 
stimuli  may  carry  one  far  past  the  danger  line  of  physiological 
breakdown  without  sounding  a  warning ;  a  lack  in  the  food  supply 
can  be  made  up  temporarily  at  the  expense  of  body  substance,  etc. 
Though  delayed  in  evidence  in  the  body,  the  cumulative  results  are 
the  same  in  both  cases;  physiological  speed-limit  regulations,  too, 
should  be  observed  strictly  under  penalty  of  the  law. 

8.  Rest  Necessary. — The  need  of  rest  furnishes  an  eighth 
parallel.  There  is  an  ingenious  machine  for  testing  the  strength  of 
metals.  Strips  of  the  metals  to  be  tested  are  put  into  this  apparatus 
and  made  to  vibrate  rapidly — ^thousands  of  times  per  minute;  the 
number  of  vibrations  occurring  before  the  strips  break  indicates  the 
relative  strength  of  the  metals.     The  number  of  vibrations  a  strip. 


HUMAN  MECHANISM  IN  RELATION  TO  HEALTH  15 

can  stand  is  directly  related  to  the  rate  of  vibration;  for  the  rate 
afEects  the  degree  of  recovery  possible  between  vibrations.  A  single 
long  rest  period  is  also  an  aid,  enabling  a  strip  to  stand  a  higher 
total  of  vibrations  than  it  can  without  such  a  rest  period.  Strips 
breaking  after  vibration,  hammering,  etc.,  show  very  different 
broken  surfaces  from  those  shown  by  strips  broken  without  such 
treatment.  This  is  taken  to  indicate  that  a  decided  rearrangement 
of  molecules  takes  place  during  action,  and  that  normal  arrange- 
ments are  reassumed  during  periods  of  rest.  Engineers  and  motor 
drivers  realize  the  value  of  such  rest  periods  for  machines  in  avoid- 
ing hot  boxes;  that  such  rest  periods  actually  prolong  the  life  of 
essential  parts  of  the  car,  engine,  etc.,  is  not  so  generally  realized. 
The  value  of  rest  periods  for  the  human  machine  cannot  be  ques- 
tioned. We  have  always  recognized  the  value  of  long  unbroken  rest 
periods  (sleep  at  night),  but  recent  investigations  have  proven  be- 
yond a  doubt  the  value  of  frequent  short  rests  in  delaying  or  pre- 
venting over-fatigue.  The  method  one  naturally  pursues  when  he 
can  control  his  own  time  is  now  scientifically  supported  and  recom- 
mended for  commercial  and  industrial  life. 

Other  Likenesses. — There  are  many  other  minor  likenesses. 
Accidents  cut  short  the  life  of  but  a  small  percentage  of  both  en- 
gines and  human  beings — less  than  5  per  cent.,  probably.  Too 
much  inactivity  or  rest  is  not  good  for  either,  for  both  rust  out. 
The  engine  does  this  literally,  but  the  body  suffers  the  same  im- 
pairment through  the  accumulation  of  fat,  the  loss  of  elasticity  and 
adaptability  in  muscles,  heart  and  other  blood  vessels.  Then,  too, 
engines,  like  people,  always  have  a  weakest  spot.  There  never  was  a 
second  "  one-hoss  shay,"  and  the  people  who  likewise  wear  out  all 
over — who  die  of  "  old  age  " — are  almost  as  rare.  Environmental 
influences  are  important  for  both  human  beings  and  machines.  Ex- 
cessive dampness  and  irritating  gases  may  predispose  to  respira- 
tory diseases  and  tuberculosis;  these  same  agents  may  cause  rust 
and  corrosion  in  important  parts  of  an  engine. 

The  body-engine  parallel  breaks  down  in  two  important  re- 
spects: (1)  The  engine  cannot  repair  itself.  Its  fuel  is  fuel  only, 
and  cannot  serve  as  material  for  growth  and  repair.  While  the 
human  body  uses  foods  mainly  for  energy  or  power,  certain  of  our 
foods  also  supply  the  essentials  for  growth  and  repair. 

(2)   The  second  important  difference  is  with  regard  to  bacterial 


16  HOME  AND  COMMUNITY  HYGIENE 

diseases.  Poor  construction,  poor  materials  in  machines  may  be 
likened  to  weak  constitutions,  low  vitality,  etc.,  in  human  beings, 
but  there  is  not  a  complete  parallel  for  disease,  for  the  machine  is 
not  subject  to  bacterial  invasion  as  human  beings  are. 

Bacterial  Action. — Bacteria  may  invade  and  weaken  any  organ 
of  the  body;  less  often  they  distribute  themselves  quite  generally 
throughout  the  body.  By  their  action  they  interfere  greatly  with 
health.  They  sometimes  secrete  poisons  or  toxins  which  irritate 
or  injure  the  body;  they  may  decompose  our  normal  foods  into 
irritating  or  non-nutritious  substances ;  and  they  may  actually  dis- 
integrate or  destroy  tissue,  as  in  ulcers. 

The  results  of  such  bacterial  action  are  more  serious  than  we 
realize.  We  "get  well,"  but  that  does  not  tell  the  whole  tale. 
Occasionally  one  seems  better  after  an  illness  than  before,  due  prob- 
ably to  the  long  rest,  better  food,  or  improved  care  taken  during  and 
even  after  the  convalescent  period.  Quite  often,  serious  effects  are 
more  evident  and  persistent.  One's  chances  for  a  long  and  vigorous 
life  are  lessened  by  every  illness;  for  the  few  who  seem  uninjured 
(and  we  can  never  predict  what  their  possibilities  might  have  been 
without  the  illness)  there  are  thousands  who  must  "walk  softly  all 
their  days." 

Keeping  Well. — Keeping  well,  however,  includes  more  than 
avoiding  infection  by  bacteria.  Such  diseases  as  nervous  affections, 
eye  weakness,  caisson  disease,  and  pellagra  may  interfere  just  as 
completely  with  one's  happiness  and  life  work  as  diseases  caused 
only  by  bacteria.  Such  diseases  and  decided  predisposition  to  many 
other  diseases  often  come  from  ignoring  the  laws  that  apply  to  man 
and  machines  both.  Yet,  it  is  not  an  uncommon  thing  to  find  an 
individual  giving  more  real  consideration  and  more  time  to  the 
well-being  of  a  motor  cycle  or  a  motor  car  than  to  his  own  health 
or  to  the  health  of  members  of  his  own  family. 

This  is  not  intentional,  of  course.  It  is  because  a  poorly  cared 
for  machine  stops  running.  It  won't  work.  But  the  body  machine 
braced  up  by  stimulants,  helped  by  high  nervous  tension,  works  on 
until  we  forget  that  there  is  "  a  limit  to  what  flesh  and  blood  can 
stand." 

The  body  must  be  fed,  exercised,  rested,  and  cared  for  to  avoid 
any  predisposition  to  disease.  Its  environment  must  be  made  safe 
and  healthful.     The  environment  includes  the  next-door  neighbor 


HUMAN  MECHANISM  IN  RELATION  TO  HEALTH  17 

who  has  smallpox ;  water  from  the  watershed  polluted  by  the  typhoid 
carrier  on  a  Pullman  train;  milk  from  a  farm  four  states  away 
where  septic  sore  throat  prevails;  the  smoky  pall  in  the  air  which 
delays  the  germicidal  action  of  the  sun  90  millions  of  miles  away; 
in  fact,  as  Sedgwick  once  defined  it,  "  Our  environment  is  that  part 
of  the  universe  that  lies  outside  ourselves/^  To  wholly  control  such 
an  environment  is  a  mighty  task. 

Personal  and  Community  Hygiene. — The  relation  between 
the  individual  and  the  environmental  factors  that  may  affect  his 
health  are  very  close  and  also  very  far  reaching.  It  is  often  difficult 
to  say  where  personal  hygiene  ends  and  public  health  begins.  What 
is  a  matter  of  personal  hygiene  to  you  individually  may  become  an 
important  phase  of  sanitation  when  you  are  responsible  for  the 
health  and  food  of  a  family  or  a  group  of  school  children.  You, 
from  habit,  never  drink  from  a  public  drinking  cup;  but  the  re- 
moval of  public  drinking  cups  from  the  school  attended  by  your 
children  is  a  matter  of  public  health  or  sanitation. 

To  live  up  to  the  implication  of  the  slogan,  "  Woman's  place  is 
in  the  home,"  would  take  her  out  of  it.  She  is  responsible  for 
safeguarding  in  every  way  the  well-being  of  the  members  of  that 
home.  She  becomes  thereby  interested  in  pure  water,  safe  milk, 
warm  lunches  for  school  children,  health  examinations  for  the 
waiters  who  serve  the  older  boys'  down  town  luncheon,  the  enforce- 
ment of  quarantine  for  the  lawless  cases  of  measles  next  door,  the 
flies  in  the  meat  market  and  the  piles  of  refuse  at  its  back  door,  the 
tubercular  clerk  in  the  laundry  who  folds  articles  ready  for  de- 
livery, the  broken  sewer  pipe  on  the  hillside  within  fly-distance  of 
the  house,  the  proposed  local  enactment  requiring  health  examina- 
tion for  domestic  helpers,  and  the  election  of  the  mayoralty  candi- 
date who  favors  school  nurses  and  free  school  clinics.  The  hygienic 
interests  of  the  individual,  the  home  and  the  community  are  essen- 
tially one  and  the  same. 

See  Reference  List  at  end  of  Appendix. 


CHAPTER  III 
FOOD 

THE  FUNCTIONS  OF  FOOD 

The  bacterial  origin  of  disease  is  so  generally  accepted  to-day 
that  we  find  it  difficult  to  realize  that  there  are  diseases  with  which 
bacteria  have  little  or  no  connection,  e.g.,  several  nervous  disorders 
and  nutritional  diseases. 

Foods  an  Important  Factor  in  Health. — Do  we  not  dismiss  as 
''  all  imagination,  anyway/'  the  pathetic  tales  of  a  "  nervous  "  pa- 
tient ?  How  many  of  us  realize  that  our  present  diet  of  good,  clean, 
attractive,  satisfying  food  may  be — ^less  promptly,  perhaps,  but  just 
as  surely — the  foundation  of  years  of  illness  and  discomfort  as  would 
food  in  a  nauseating  state  of  decomposition  ? 

We  all  agree  (1)  that  food  should  not  convey  pathogenic  (G) 
organisms  {e.g.,  tuberculosis  in  beef,  butter,  milk)  ;  (2)  that  it 
should  not  be  deleteriously  affected  by  other  micro-organisms  {e.g., 
those  forming  ptomaines  (G)  in  cheese  or  fish)  ;  and  (3)  that  it 
should  not  be  preserved,  stored,  or  prepared  in  any  way  injurious  to 
man  {e.g.,  the  copper  greening  of  peas).  But  it  is  just  as  imj^or- 
tant  that  our  daily  food  should  include  the  proper  proportions  of 
proteins,  fats,  etc.,  and  absolutely  essential  that  certain  foods  little 
valued  by  the  general  public  {e.g.,  fruits,  milk)  should  form  part 
of  every  diet,  especially  that  of  children. 

That  we  should  "  eat  to  live  "  not  "  live  to  eat "  has  been  the 
ideal  held  up  to  us  from  childhood.  But  that  is  merely  a  check  on 
the  amount  eaten;  and  beyond  a  few  wholly  mistaken  ideas,  such 
as  "  fish  makes  brains,"  we  are  very  vague  about  wliat  we  should  eat. 

To  answer  that  query  we  must  first  know  the  functions  of  food 

in  the  human  body.     Ask  your  nearest  neighbor  that  question  and 

the  answer  will  be  "to  keep  well,"  "to  keep  alive,"  "to  make 

blood,"  "  to  keep  up  our  strength,"  "  you  can't  work  without  food," 

18 


FOOD  19 

or  a  similar  vague  answer.  But  which  foods  are  absolutely  essen. 
tial  to  health,  how  much  food  we  need  to  keep  alive,  or  to  do  the 
work  allotted  to  us,  or  what  foods  should  compose  the  dietary  of 
the  growing  child,  the  hard-working  adult,  or  the  invalid,  are 
problems  most  of  us  never  even  recognize  as  problems. 

For  some  years  many  investigators  in  chemistry  and  physiology 
and  the  allied  sciences  of  bacteriology  and  nutrition  have  worked 
at  these  problems,  and  at  last  we  are  near  a  complete  answer  to  the 
question.  What  are  the  functions  of  food  in  the  human  body  ? 

Functions  of  Food. — Food  serves  three  general  purposes  or 
functions^  in  the  body:  (1)  It  furnishes  energy.  (2)  It  supplies 
the  material  for  growth  and  repair.  (3)  It  regulates  the  body 
processes  (this  last  use  is  illustrated  by  iron,  which  is  necessary  for 
the  formation  of  hemoglobin  in  the  red  corpuscles). 

Having  stated  the  three  functions  of  food,  it  remains  to  be 
seen  how  these  three  functions  are  satisfied  by  the  five  following 
divisions  of  foodstuffs:  fats,  carbohydrates  (G),  proteins  (G), 
minerals,  and  vitamines  (see  p.  27). 

Food  as  Fuel. — Food  supplying  energy  can  be  considered  as 
fuel.  That  it  is  burned  or  oxidized  in  the  human  body  instead  of  a 
furnace  does  not  affect  the  matter  at  all,  except  that  an  appropriate 
form  of  fuel  must  be  used.  All  fuels  are  primarily  carbon  com- 
pounds, and  human  beings  are  limited  to  such  carbon  compounds  as 
sugar  and  fats,  and  are  not  able  to  use  such  forms  as  coal,  wood,  or 
carbon  dioxide. 

An  engineer  knows  exactly  how  much  work  a  given  amount  of 
fuel  can  do.  He  estimates  it  by  the  weight  it  can  lift  or  by  the  heat 
it  gives  out.  ^Ye  do  not  find  the  units  of  weight  (foot-pounds,  or 
horsepower)  suited  for  determining  the  fuel  value  of  our  foods; 
but  measure  their  relative  energy  values  by  heat  units,  or  calories. 
The  following  table  of  100-calorie  portions  illustrates  the  variation 
in  the  fuel  values  of  some  of  our  common  foods. 

^This  whole  matter  may  seem  to  belong  to  human  physiology  rather 
than  general  hygiene.  But  so  long  as  one  person  controls  the  dietaries 
of  a  number  of  people  {e.g.,  the  mother  in  the  home,  the  manager  in  the 
hotel  or  boarding  house ) ,  a  brief  review  of  foods — their  function  and 
their  values — should  be  part  of  the  discussion  of  home  and  community 
problems. 


20 


HOME  AND  COMMUNITY  HYGIENE 


Amounts  of  Food  Yielding  100  Calobies 


Apple — 1  large  or  2  medium  size 

Banana — 1 

Beets— 3 

Bread — 2  one-half  inch  slices 

Butter — 1  tb.  (tablespoon) 

Cheese— 1    slice    21/2"  X  3"  X  1/4" 

Cornmeal — 1/4  c.   (cup) 

Cream  of  wheat  (uncooked) — 3  tb. 

Dates — 4 

Dried  peas  or  beans — 2  tb. 

Eggs— 11/2 

Graham  crackers — 3  large 

Macaroni — 14  c. 


Milk    (whole)— %   c. 
Orange — 1   large 
Peanut  butter — 1  tb. 
Peanuts    (whole) — 11-15 
Potato — 1  medium 
Prunes — 4  or  5 
Puffed  wheat — 1%  c. 
Raisins — 11 

Shredded  cabbage — 5  c. 
Shredded  wheat  biscuit — 1 
Sugar — 2  tb. 
Walnuts— 8 


Fats. — This  difference  in  fuel  value  is  explained  by  referring  to 
the  next  table;  notice  how  much  richer  butter  is  in  carbon  and 
hydrogen. 


Foods 


Carbon 


Cane  sugar ...    42  per  cent 

Starch 44  per  cent. 

Butter 


Milk    protein 
(casein) .  .  .  . 


Hydrogen 


Oxygen 


6  per  cent.  1  52  per  cent. 


75  per  cent.  '  12 
53  per  cent 


6  per  cent.  49  per  cent, 
per  cent.  13  per  cent. 

7  per  cent.  !  23  per  cent. 


Nitrogen 

Available 
calories 
per  gram 

— 

4 

- 

4 

- 

9 

16  per  cent. 

4 

Both  carbon  and  hydrogen  unite  "vrith  oxygen,  yielding  energy, 
and  butter  has  about  twice  as  much  carbon  and  hydrogen  as  sugar, 
starch,  or  protein.  Butter  has  also  less  oxygen  and,  therefore,  has 
less  of  its  hydrogen  and  carbon  already  united  with  oxygen,  so  it  is, 
as  the  table  shows,  more  than  twice  as  good  a  fuel  as  the  other 
substances.  Fat  is,  therefore,  a  very  compact  fuel,  and  we  are  all 
familiar  with  the  fact  that  fat  is  a  favorite  food  of  those  living  in 
very  cold  regions.  It  is  also  a  good  addition  to  the  diet  of  those 
doing  heavy  work,  as  it  may  easily  be  added  as  almost  pure  fat 
{e.g.,  olive  oil,  butter)  and  give  the  increased  fuel  value  needed 
without  upsetting  the  food  balance  {e.g.,  adding  unnecessary  pro- 


FOOD  21 

tein).  Fats  are  less  likely  to  form  objectionable  products  than  are 
proteins  and  carbohydrates.  They  do,  however,  delay  the  secretion 
of  gastric  juices,  and  grease-covered  particles  (as  in  hard-fried 
foods)  may  not  be  properly  digested.  That  excess  food  fats  may  be 
stored  in  the  body  is  now  accepted;  but  that  is  no  excuse  for  over- 
feeding with  fats.  It  is  inadvisable  to  carry  about  so  much  "  dead 
weight "  of  fat ;  fats  in  large  amounts  may  induce  nausea ;  there  are 
also  individual  digestive  differences  that  may  limit  the  use  of  fats 
as  food. 

Eecent  investigation-  indicates  that  some  fats  have  more  than 
their  energy  value  to  recommend  them.  Most  fats  vary  little  in 
their  food  values  or  digestibility,  but  milk  and  egg  fats  contain 
substances  necessary  for  growth,  which  lard  and  certain  other  fat 
substitutes  for  butter  do  not  contain  (vitamines,  p.  27). 

Sherman  suggests  that  many  people  are  using  more  fat  than 
their  energy  requirement  would  warrant  (less  than  half  a  pound 
per  week) ;  he  recommends  that  they  consider  whether  or  not  some  of 
that  money  should  not  be  spent  for  milk.  "  A  pound  of  butter  is 
equal  iui  energy  value  to  5  quarts  of  milk,  but  in  view  of  the  pro- 
teins and  ash  constituents  which  the  milk  contains,  it  would  prob- 
ably be  wise  to  consider  that  3  quarts  of  milk  fully  equal  1  pound 
of  butter  as  an  asset  in  the  dietary,  except  perhaps  in  those  cases 
in  which  the  energy  problem  distinctly  predominates.  To  pay 
much  if  any  more  for  a  pound  of  butter  than  for  3  quarts  of  milk 
will  usually  mean  either  that  an  extravagant  price  is  being  paid 
for  buttfer  or  that  the  milk  used  is  below  the  quality  which  the 
consumer  can  afford  and  should  demand." 

Carbohydrates. — ^The  main  energy-yielding  foods,  however,  are 
not  the  fats  but  the  carbohydrates.  Starchy  foods,  such  as  cereals, 
bread,  and  potatoes,  form  a  large  parj:  of  our  diet,  and  rightly  so ; 
for  potatoes  and  whole-floured  cereals  and  grains  contain  a  favor- 
able proportion  of  protein  and  many  of  them  contain  those  impor- 
tant but  mysterious  vitamines.  Cereal  and  grain  foods  as  served  on 
the  table  are  commonly  50  to  80  per  cent,  starch.  Sugars  alone  are 
credited  with  supplying  one-fifth  of  our  energy  requirement.  Ordi- 
nary cane  and  beet  sugars  are  practically  pure  substances  and  well- 
adapted  for  use  as  emergency  additions,  as  their  increase  will  not 
require  other  adjustments  of  the  dietary  as  would  foods  which  eon- 
tain  protein.     As  a  nation  our  per  capita    sugar  consumption  is 


22  HOME  AND  COMMUNITY  HYGIENE 

unusually  high,  85  pounds  per  year.  The  pre-war  average  for  the 
six  largest  European  countries,  England  excepted,  is  but  26  pounds. 

Those  responsible  for  the  feeding  of  others  should,  however, 
recognize  the  possible  evils  of  overfeeding  with  sugar.  Too  high  a 
percentage  of  sugar  is  irritating  to  the  mucous  membranes;  Sher- 
man illustrates  this  by  citing  the  effect  on  the  mouth  lining  as 
candy  slowly  dissolves  in  the  mouth.  Sugar  is  mainly  absorbed  in 
the  small  intestine ;  but  delay  in  passing  from  the  stomach  or  other 
digestive  disturbances  may  allow  the  sugar  to  ferment.  This  means 
not  only  a  loss  of  food  value,  but  causes  pain  or  other  discomfort 
due  to  the  gases  or  acids  formed.  Another  reason  for  reducing  the 
amount  and  concentration  of  sugar  in  the  diet  is  that  overeating  of 
sweets  dulls  the  appetite,  and  causes  a  mawkish  feeling,  or  even 
nausea.  Sugar  so  affects  the  sense  of  taste  that  the  natural  flavors 
of  cereals,  whole  wheat  bread,  and  delicate  green  vegetables  make 
but  little  appeal,  leading  to  a  lessened  intake  of  the  foods  often  most 
valuable  in  nutrition.  Fresh  fruits — to  appetites  not  dulled  by 
sugar — offer  a  pleasing  form  of  sugar,  usually  with  valuable  mineral 
and  vitamine  additions. 

Carbohydrates  are  readily  stored  as  fat  (and  glycogen  (G)). 
If  food  is  in  excess  of  the  actual  needs,  it  is  probably  best,  consider- 
ing the  effect  of  fats  upon  appetite  and  digestion,  that  the  excess 
should  be  carbohydrates. 

Proteins. — Protein  foods  may  be  utilized  for  the  production  of 
energy,  for,  as  the  table  on  page  20  shows,  they  equal  carbohy- 
drates in  fuel  value.  Their  most  important  use,  however,  is  as 
building  material:  (1)  for  growth  of  new  tissue  (growing  child), 
and  (2)  for  the  constant  repair  of  old  tissue.  For  these  building 
or  upbuilding  processes  about  60  grams  (about  2  oz.)  of  protein  are 
needed  daily;  usually  10  to  15  per  cent,  of  the  caloric  value  of  our 
food  should  be  in  proteins.  Meat  and  eggs,  the  protein  foods 
highest  in  popular  esteem,  have  proportionately  high  prices,  and 
most  people  naturally  use  as  sources  of  energy  the  cheaper  fuel 
foods,  the  carbohydrates.  An  economical  diet,  therefore,  includes 
only  the  necessary  amount  of  protein,  making  up  the  required 
caloric  total  by  the  addition  of  foods  poor  in  or  totally  lacking 
protein.  If  the  starches,  sugars,  and  fats  are  sufficient  to  complete 
the  total  energy  requirements,  the  proteins  are  said  to  be  protected, 


FOOD  23 

and  are  wholly  available  for  building  purposes;  in  this  sense,  car- 
bohydrates and  fats  are  spoken  of  as  protein-saving  foods. 

All  diets  do  not  include  suflficient  protein.  "  A  quart  of  milk  a 
day  for  every  child "  will  insure  the  necessary  protein,  as  19  per 
cent,  of  the  fuel  value  of  milk  is  protein  in  easily  available 
form.  The  dietaries  of  the  very  poor  and  of  people  with  very 
strong  "  likes  and  dislikes "  are  sometimes  deficient  in  protein. 
The  processes  of  food  preparation  reduce  unduly  the  proportion  of 
protein  in  some  of  our  most  important  foods,  e.g.,  "  polished  rice." 
Fads  have  been  responsible  for  some  cases  of  underfeeding  and 
malnutrition,  especially  among  children. 

Excess  Protein. — Since  proteins  are  so  essential  to  health,  the 
natural  inclination  is  to  eat  plenty  of  them — to  be  sure  we  have 
enough.  Hearty  eaters — particularly  those  who  like  the  physical 
sense  of  being  well-fed,  who  want  something  "  to  stay -by  "  them 
until  the  next  meal,  often  overfeed  with  proteins,  as  proteins  are 
slower  in  leaving  the  stomach  than  carbohydrates.  This  is  not  a 
good  plan,  for  though  excess  proteins  can  be  used  as  fuel  or,  to 
some  extent  at  least,  stored  as  fat,  they  are  not  desirable  as  the 
source  of  either  fuel  or  fat.  Proteins  are  not  easily  cared  for  in 
the  body.  They  entail  too  much  work  for  the  digestive  apparatus, 
and  the  strain  on  the  excretory  organs  is  needlessly  increased. 

Lusk  states  that  "  meat  stimulates  the  body  to  a  higher  heat 
production,  as  great  as  55  per  cent,  having  been  observed  in  a  rest- 
ing man."  This  is  due  to  the  peculiar  character  of  protein. 
Since  this  heat  cannot  be  "  utilized  in  the  execution  of  mechanical 
work,"  its  production  and  its  elimination  are  both  wasteful  processes. 
Lusk  also  adds  that  the  false  idea  of  the  necessity  of  meat  has 
come  through  the  following  faulty  reasoning :  "  A  strong  man  can 
eat  more  meat  than  a  weak  one,  hence,  meat  makes  a  man  strong." 
The  large  number  of  people  suffering  from  liver  and  kidney 
diseases,  especially  after  middle  age  is  reached  (see  p.  300),  when 
the  cumulative  effect  of  such  overstrain  of  the  organs  might  be 
expected  to  show  up,  indicates  the  need  for  protein  limitation^  espe- 
cially where  there  is  a  family  history  of  kidney  or  liver  disease. 
Proteins  are  more  likely  to  undergo  undesirable  putrefaction  in  the 
intestines,  leading  to  "  auto-intoxication "  or  other  digestive  dis- 
turbances. With  increasing  age,  the  protein  limit  should  be  in- 
creasingly emphasized,  reducing  it  in  proportion  to  the  reduction  in 


24  HOME  AND  COMMUNITY  HYGIENE 

the  total  calories,  as  older  people  are  less  able  to  deal  with  a  protein 
excess. 

Almost  all  authorities  recommend  a  considerable  reduction  in 
the  meat  eaten  on  economic  grounds:  (1)  The  food  necessary  to 
fatten  the  meat-animals  could  be  more  economically  used  directly 
by  man.  Man  could  get  twelve  times  the  fuel  value  from  the 
corn  represented  in  a  slice  of  pork  that  he  gets  from  that  piece  of 
pork.  (2)  Cows  should  be  used  for  milk  and  less  for  meat,  a  cow  in 
good  condition  will  give  in  one  year  milk  containing  "  as  much 
protein  and  two  and  one-half  times  the  number  of  calories  as  are 
contained  in  her  own  body." 

The  use  of  vegetables  as  a  source  of  protein  (whole  wheat,  po- 
tatoes in  their  ''^jackets,"  unpolished  rice,  peas,  beans)  is  not  only 
economical  but  desirable ;  for  in  such  foods  proteins  are  found  in  the 
(10  to  15  per  cent.)  proportion  desirable  in  the  average  diet. 
Such  foods  are  also  coarser  in  texture  or  contain  indigestible 
residues  that  have  helpful  effects :  they  promote  peristaltic  action 
and  contain  one  or  more  laxative  elements  that  help  counteract  the 
tendency  to  constipation,  a  condition  but  too  prevalent,  and  by  many 
explained  as  due  to  a  sedentary  life  or  to  the  present  too  condensed 
and  over-refined  dietaries. 

The  food  problems  are  not  settled  when  one  has  determined  the 
amount  of  protein  necessary  for  growth  (including  repair)  and 
added  to  it  sufficient  amounts  of  fats  and  carbohydrates  to  supply 
the  energy  requirement.  Some  foods  on  being  broken  up  in  the 
body  yield  acid  substances ;  eggs,  fish,  and  meat  are  good  examples 
of  such  acid-formers.  The  blood  and  body  tissues  generally  are 
neutral  or  slightly  alkaline.  Acid  accumulations  from  such  foods 
are,  therefore,  injurious  to  the  body  (acidosis)  and  must  be  neu- 
tralized by  alkaline  or  basic  substances.  Many  other  foods — ^fruits 
and  vegetables  generally — yield  such  basic  substances;  good  ex- 
amples of  such  base-formers  are  prunes,  raisins,  potatoes,  carrots, 
spinach,  celery,  rutabaga,  beans,  and  beets.  With  meat  or  fish, 
then,  one  should  eat  a  sufficient  amount  of  base-forming  food,  (the 
acid  formed  by  one  hundred  calories  of  meat  is  neutralized  by  one 
hundred  calories  of  potato).  Grains  generally  are  acid-formers; 
rice,  therefore,  may  be  substituted  for  potatoes  as  a  source  of  eneTgy, 
but  not  as  a  complement  to  meat  to  neutralize  its  acid  products. 


FOOD  25 

Attention  to  the  "  type  "'  of  protein  is  also  necessary,  especially 
in  children's  diets;  e.g.,  such  proteins  as  zein  from  corn  cannot  com- 
pare with  the  phospho-proteins  of  milk  and  eggs  as  materials 
for  gro^rth. 

Minerals. — Another  important  problem  is  the  mineral  ^  require- 
ment. It  was  formerly  thought  that  a  diet  filling  the  protein  and 
energy  requirements  would  provide  adequately  for  the  mineral  needs 
of  the  body.  This,  unfortunately,  is  far  from  true,  especially  for 
the  essential  minerals,  calcium,  phosphorus,  and  iron.^ 

The  total  daily  mineral  requirement  for  an  adult  is  between  18 
and  28  grams  (0.6  oz.  to  1  oz.).  Dietaries  often  lack  the 
requisite  amounts  of  one  or  more  of  these  elements :  calcium,  for 
little  children  if  milk  is  not  the  principal  part  of  the  diet;  iron, 
most  essential  for  growth,  though  present  in  the  body  in  very  small 
amounts  (less  than  three  grams  or  about  Vg  oz.). 

Dietaries  containing  the  full  minimum,  requirements  for  each 
mineral  may  be  unsatisfactory  because  of  the  proportion  of  the  sev- 
eral substances.  Overfeeding  with  potassium  causes  a  sodium  or 
salt  craving.  Too  little  salt  causes  a  disinclination  for  potassium 
foods,  such  as  potato,  which  may  otherwise  be  a  necessar}'  part  of 
the  diet;  too  much  salt  interferes  with  the  utilization  and  absorp- 
tion of  food.  A  comparison  of  many  dietaries  shows  that  they  are 
quite  generally  deficient  in  calorie  and  in  mineral  requirements, 
though  they  are  less  often  lacking  in  proteins.  Since  proteins  are 
usually  our  more  expensive  foods,  this  indicates  that  the  lack  is 
due  to  ignorance  and  carelessness,  rather  than  to  lack  of  money. 
The  "  margin  of  safety" "  for  minerals,  Sherman  warns  us,  is  small, 
and  since  there  is  some  doubt  that  all  of  them  can  be  taken  in  inor- 
ganic form,  as  medicines,  attention  must  be  given  to  their  presence 
in  our  daily  diet. 

*  The  importance  of  water  might  -^eW  be  included  here.  It  is  a  neces- 
sary solvent,  for  all  foods  must  be  in  solution  before  they  can  be  taken 
into  the  cells.  Its  importance  as  an  aid  in  excretion  cannot  be  over- 
estimated. At  least  two  quarts  of  water  should  be  taken  daily;  there  is 
little  danger  from  overdrinking  water.  There  is  a  popular  impression 
that  water  should  not  be  taken  with  meals;  it  is  not  harmful  unless 
very  cold. 

'  The  other  important  minerals  are  potassium,  sulphur,  magnesium, 
sodium,  and  chlorine.  Some  of  these  minerals  are  present  in  the  body 
in  striking  amounts;  e.g.,  calcium  constitutes  2i/^  pounds,  eodiuni,  1/5 
pQund,  and  potassium,  ^^  pound  of  the  average  body  weight. 


26  HOME  AND  COMMUNITY  HYGIENE 

Certain  of  the  minerals  are  obtained  in  favorable  form  and 
amounts  from  animal  proteins,  e.g.,  calcium  from  milk  and  sulphur 
from  eggs.  Fruits  and  vegetables,  especially  the  outer  layers,  are 
fortunately  rich  in  minerals. 

Although  vegetables  and  fruits  contain  the  necessary  minerals 
and  in  utilizable  form,  it  is  sometimes  difficult — with  present-day 
methods — ^to  provide  the  full  amount.  The  common  methods  of 
food  preservation  and  our  over-refinements  of  food  preparation  so 
generally  discard  the  outer  coverings  of  grains,  fruits,  and  vege- 
tables, that  a  large  part  of  these  minerals  is  lost.  Graham,  who 
advocated  a  whole  wheat  flour,  warned  against  such  over-refine- 
ments, saying  that  we  "might  discard  something  of  value.''  We 
lose,  of  course,  in  lump  food  value  by  these  methods:  100  pounds 
of  wheat  yield  100  pounds  of  graham  flour,  and  but  85  pounds  of 
entire  wheat  flour,  or  but  73  pounds  of  standard  "patent"  flour. 
That  the  difference  is  used  for  cattle  is  little  cause  for  congratula- 
tion, when  we  realize  that  the  discarded  28  pounds  contain  almost 
all  of  the  essential  minerals. 

We  have  overemphasized  the  appearance  of  our  foods.  In  the 
effort  to  secure  dainty  effects  we  have  blindly  discarded  the  nutty 
brown  bread,  thinking  that  the  whiteness  compensated  for  the 
"  flat "  taste.  Our  losses  are  just  as  great  in  polished  rice,  peeled 
potatoes,  pared  fruits,  and  blanched  nuts.  A  little  kitchen  maid 
who  had  peeled  the  onions  and  potatoes,  shelled  the  wax  beans, 
peeled  the  tomatoes,  and  then  peeled  the  peaches  for  dessert,  was 
more  right  than  she  dreamed  when  she  wished  forlornly  that 
"  something  would  grow  without  skins."  To  any  sensible  person  so 
much  handling  of  food  is  a  waste  of  time;  when  not  followed  by 
cooking,  it  may  be  decidedly  unpleasant  to  contemplate. 

The  importance  of  such  minerals  so  discarded  is  shown  by  the 
following  facts : 

1.  Mineral  salts  are  absolutely  necessary  to  maintain  the  normal 
alkalinity  of  the  tissues. 

3.  Cell  activity  {e.g.,  nervous  and  muscle  irritability)  is  affected 
by  the  mineral  constituents  of  the  blood. 

3.  Eesistance  to  disease  is  increased  (directly  or  indirectly)  by 
using  foods  high  in  certain  minerals;  e.g.,  calcium  feeding  aids  in 
combating  tuberculosis. 

4.  Prolonged  deficiency  of  certain  minerals  results  in  such  "  de- 


Pood  27 

ficiency  diseases  "  as  scurvy  (potassium; see  vitainiues,  below),  bone- 
malformations  (calcium),  and  anasmia  (iron). 

5.  Certain  mineral  salts  are  necessary  for  growth.  Experiments 
made  on  rats  show  that  without  iron  the  growth  is  one-fourth  the 
normal  rate. 

We  have  considered  three  of  the  necessary  factors  in  any  ade- 
quate food  supply:  (1)  Fuel  or  energy  foods;  (2)  proteins  for 
growth  and  repair;  (3)  minerals,  shown  to  be  absolutely  necessary 
for  growth  or  health.  A  fourth  essential  factor  remains  for  con- 
sideration— the  vitamines. 

Vitamines. — The  name,  vitamine/  was  first  used  in  1911  for  a 
substance  extracted  from  rice  bran  in  an  attempt  to  find  the  cause 
of  that  nutritional  disease,  beri-beri,  associated  with  diets  of  "  pol- 
ished "  rice  (lacking  the  outer  or  bran  layers).  Similar  sub- 
stances having  the  power  to  cure  or  prevent  beri-beri  are  obtained 
from  yeast,  potatoes,  meat,  and  fresh  milk.  Scurvy,  also  common 
among  people  such  as  sailors  kept  for  a  long  time  on  a  restricted 
or  deficient  diet,  may  be  similarly  prevented  by  the  use  of  certain 
vegetables  (carrot,  potato)  and  fresh  fruits  (pineapple,  orange,  even 
orange  peel).  These  vitamines  are  still  incompletely  known:  their 
presence  or  absence  does  not  affect  chemical  analyses  of  the  sub- 
stances containing  them,  and  they  are  considered  by-products  occur- 
ring in  metabolism — not  the  results  of  mere  digestion.  All  that 
most  reliable  authorities  are  yet  willing  to  say  is  that  they  are 
basic  nitrogeneous  substances ;  that  they  may  be  affected  somewhat 
by  heat;  and  that  there  are  at  least  three  vitamines,  a  fat-soluble 
vitamine  (type  A)  and  two  water-soluble  vitamines  (types  B  and 
C ) .  These  are  found  in  the  substances  already  mentioned  and  many 
others,  including  legumes,  cod  liver  oil,  etc.^  The  vitamines  differ 
in  the  amount  of  heat  they  can  withstand.  Pasteurized,  dried  and 
canned  milk  do  not  differ  materially  from  fresh  milk  in  vitamine 
values;®  potatoes  may  be  boiled  without  losing  their  vitamine  effi- 

^The  first  part,  vit,  was  used  to  indicate  its  necessity  for  life:  tlie 
second  part,  amines,  because  it  was  thouglit  related  to  those  nitrogeneous 
substances. 

^Vitamines  are  formed  in  the  leaves  of  plants;  it  is  thought  that 
animals  merely  "condense"  them.  The  valuable  animal  sources  are  milk, 
butter,  beef  fat  margarine,  and  eggs. 

"For  babies  orange  or  tomato  juice,  or  potato  water  may  be  used  to 
supply  any   deficiency  in  the  scurvy  vitamine. 


28  HOME  AND  COMMUNITY  HYGIENE 

ciency.  Suitable  additions  to  the  diet  of  soldiers  and  sailors  have 
stamped  out  sc-urvy  and  beri-beri.  This  indicates  that  they  are 
"  deficiency  diseases."  Investigations  indicate  that  pellagra  is  defi- 
nitely related  to  the  lack  of  calcium  and  vitamines.  Both  the  fat- 
soluble  and  water-soluble  types  of  vitamines  studied  have  been 
shown,  in  experimental  work,  to  be  essential  for  growth,  as  well  as 
health.  Xot  only  must  diets  be  balanced  along  fuel  and  building 
lines;  they  must  also  contain  sufficient  amounts  of  minerals  and 
these  as  yet  unanalyzed  and  unmeasured  vitamines. 

Balanced  Diets. — "  To  eat  to  live  "  is  no  simple  task,  appar- 
ently. Diets  balanced  in  regard  to  these  four  considerations  are  not 
easily  planned.  "  To  eat  what  we  like  "  may  at  times  satisfy  cravings 
that  should  be  satisfied  {e.g.,  the  herbivorous  craving  for  salt, 
which  is  not  shared  by  carnivorous  animals,  who  obtain  sufficient 
salt  from  the  flesh  eaten).  It  is  not  a  safe  rule,  however,  unless,  as 
Stiles  suggests,  we  "  extend  the  range  of  our  liking."  Every  effort 
should  be  made  to  develop  in  children  a  more  catholic  taste.  There 
are  occasional  "  food  sensitives  "  who  cannot  eat  strawberries,  lob- 
ster, milk,  or  eggs  in  certain  forms,  etc.  Such  conditions  may  be, 
Vaughn  suggests,  the  fault  of  early  feeding  (see  p.  210).  True 
"  protein  sensitives  '^  are,  not  very  common,  and  most  children  may 
safely  be  taught  to  like  a  wide  range  of  foods. 

An  interesting  illustration  of  a  balanced  diet  is  given  by  Lusk 
in  the  peasants  of  southern  Italy,  who  "live  mainly  on  cornmeal, 
olive  oil,  and  green  stuff's,  and  have  done  so  for  generations.  There 
is  no  milk,  cheese,  or  eggs  in  their  dietary  Meat  in  the)  'form  of  fat 
pork  is  taken  three  or  four  times  a  year.  Cornmeal  is  taken  as 
'^polenta'  or  is  mixed  with  beans  and  oil,  or  is  made  into  corn 
bread.  Cabbage  or  the  leaves  of  beets  are  boiled  in  water  and  then 
eaten  with  oil  flavored  with  garlic  or  Spanish  pepper." 

Corn,  lacking  one  desirable  protein,  and  olive  oil,  lacking  in 
minerals  and  vitamines,  if  supplemented  by  green  leaves  which  fur- 
nish the  additional  proteins,  minerals  and  vitamines,  make  a  sus- 
taining, balanced  diet.  (Incidentally,  this  cheapest  of  cereals  and 
a  cheap  vegetable  oil  cost  the  Ittalian  peasants  but  three  cents  per 
day  under  pre-war  conditions  !) 

Amount  of  Food  Needed. — Having  discussed  thus  briefly  the 
uses  of  the  various  foodstuffs,  there  remains  still  the  important 


FOOD  29 

question,  How  much  of  these  foodstuffs  is  necessary  for  the  complete 
nourishment  of  the  body?  The  evils  of  undereating  are  implied 
throughout  the  preceding  pages;  with  lack  of  energy  and  strength, 
lack  of  storage  for  emergencies,  loss  of  weight,  imperfect  growth, 
anaemia,  and  the  other  deficiency  diseases,  must  be  included  the  less 
direct  effects  of  sleeplessness,  sensitiveness  to  cold,  and  mental  de- 
pression and  irritability.  These  occur  not  only  in  the  evidently 
starving,  but  in  people  whose  diet  is  ill-chosen. 

Overeating  is  more  common,  probably,  than  undereating. 
Hunger  is  not  a  reliable  guide,  especially  if  one  eats  rapidly.  The 
evils  of  over-protein  feeding  have  already  been  discussed.  Any 
form  of  overeating  throws  extra  work  upon  the  organs  of  digestion 
and  elimination,  leading  often  to  permanent  enlargements,  degen- 
erative changes,  and  causing  predisposition  to  disease.  Indigestion 
in  its  varied  forms,  liver  and  kidney  diseases,  gout,  arthritis,  some 
forms  of  eczema,  and  a  general  disinclination  to  mental  and  physi- 
cal exertion  (especially  in  the  very  obese)  are  evils  not  measurable 
in  terms  of  gastronomic  pleasures. 

How  much  we  shall  eat  is  a  very  important  problem.  It  is  so 
comprehensive  that  we  cannot  do  more  in  a  book  on  general  hygiene 
than  state  the  general  conditions  and  variations.  Anyone  responsi- 
ble for  the  feeding  of  others  should  consult  up-to-date  authorities  ^ 
on  nutrition.  With  regard  to  this  point  Sherman  gives  the  follow- 
ing :  "  If  from  year  to  year  the  body  keeps  in  good  condition  for  its 
work  and  maintains  a  fairly  constant  weight  which  bears  such  a 
proportion  to  the  height  as  to  show  that  a  proper  amount  of  fat  is 
being  carried,  it  is  reasonably  certain  that  the  amount  (fuel  value) 
of  food  eaten  in  the  course  of  the  year  is  substantially  that  which  is 
suited  to  the  degree  of  activity  maintained.  If,  however,  by  follow- 
ing the  appetite,  one  becomes  unduly  stout  or  unduly  thin,  or  does 
not  get  sufficient  fuel  for  the  energy  required  for  the  day's  work,  or 
is  annoyed  by  digestive  disturbances  indicative  of  improper  feeding, 
it  is  certain  that  the  appetite  is  in  this  case  not  a  perfect  standard. 
Still  more  often  will  the  individual  appetite  prove  an  inadequate 
guide  to  such  a  quantitative  combination  of  the  different  types  of 

^  Several  give  the  fcwd  needs  in  ounces,  in  ordinary  portions,  or  in 
other  easily  determined,  units,  e.g.,  slices  of  bread,  spoonfuls  of  butter  and 
cupfuls  of  milk. 


30  HOME  AND  COMMUNITY  HYGIENE 

food  as  shall  lead  to  a  well-balanced  intake  of  each  of  the  many 
essential  food  constituents." 

Our  highest  authorities  disagree  somewhat  with  regard  to  the 
total  amount  of  food  necessary,  and  the  proportion  of  protein  neces- 
sary or  wise.  A  fair  average  is  3000  calories  per  day  for  an  adult 
at  ordinary  labor  (2100-2300  for  light  labor  ^)  with  the  protein 
forming  10  to  15  per  cent,  of  that  total.  Even  when  at  rest — lying 
down  or  sleeping — considerable  food  is  necessary,  about  1650  to 
1850  calories  per  day.  The  weight  of  the  body  must  also  be  con- 
sidered, for  twice  the  weight  means  about  twice  the  tissue  to  be 
nourished ;  it  also  means  twice  as  much  energy  for  locomotion.  The 
relative  body  surface  has  an  important  bearing,  and  children 
(having  relatively  more  surface  per  pound  of  weight)  have  relatively 
increased  food  needs.® 

Convalescents  and  growing  children  need  more  of  the  building 
stuffs  (proteins,  minerals,  vitamines)  per  pound  than  do  adults; 
their  greater  activity  and  the  surface  ratio  just  mentioned  do  not 
change  materially  the  ratio  of  proteins  to  the  energy  or  fuel  foods, 
however.  With  increasing  old  age  both  the  fuel  and  protein 
needs  decrease. 

Family  Expenditures. — Even  though  one  sensibly  attempts  to 
secure  a  daily  balance  (not  a  meal  balance)  it  is  far  from  easy  to 
plan  a  pleasing  and  inexpensive  dietary  for  a  family  composed  in- 
evitably of  members  showing  most  of  the  varied  conditions  just 
mentioned.  A  study  of  the  dietaries  of  many  hundred  families 
shows  that  they  tend  to  spend  too  much  for  proteins — and  for  the 
more  expensive  proteins — and  too  little  for  milk.  Slogans  to 
remedy  this  are  coming  into  use :  "  Three  pints  of  milk  a  day  for 
every  child " ;  "  ISTo  meat  until  three  quarts  of  milk  have  been 
bought";  "As  much  for  fruit  and  vegetables  as  for  meat  and 
fish";  "As  much  for  milk  (and  cheese)  as  for  meat  (and  fish)." 
This  replacement  of  meat  by  milk  occurs  in  the  following  percentage 
dietary  for  four  adults  and  three  growing  children  recommended  by 

^Mental  work,  for  example,  demands  little  increase  in  food  value; 
the  brain  mass  is  but  about  2  per  cent,  of  the  whole  body  mass,  and  its 
activity  could  have  but  little  effect  upon  the  total  body  metabolism.  Emo- 
tional expenditures  make  much  greater  demands,  however,  because  they 
affect   gland   and    muscle   activities. 

*  Accordingly,  a  baby  one  year  old  needs  twice  the  calories  per  poiind 
that  its  parents  do. 


FOOD  31 

Sherman;  its  proportion  of  fruits  and  vegetables  (as  well  as  milk) 
also  recognizes  that  our  money  must  buy  the  essential  minerals  and 
vitamines  as  well  as  the  foodstuffs  that  can  be  measured  in  calories. 

Per  cent,  of 

total  cost  of 

food 

Meats,  poultry,  and  fish 10-15 

Eggs   5-7 

Milk    25-30 

Cheese    2-3 

Butter  and  other  fats    10-12 

Bread,  cereals,   and  other  grain  products    12-15 

Sugar,  molasses,  and  syrups  about  3 

Vegetables  and  fruits 15-18 


Some  Foods  Supply  Building  Stones 
More  Economically  than  Others 

The  length  of  the  line  opposite  the  food  given  below  indicates  the  return  in  food  value  for  the  money  spent 

or  Cheese           ^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^| 

^^^^^^^^^^^^^B^^^H 

Meat  Egg>  or                ^^^^^^^^^^^^H 

Bo,.   «ml   &rl.    Nc«l    M«n,    lUxJ. 

of   -BuiUiog   Stone-   lo 

Grow    Vkgorotuly 

rrrrf  (nwin.  bojt  Of  iirL     Bays  .nd  gitb  ■!»  n«d 

FOOD  CHART 

Vo.Vl 

Fig.  14. — One  of  the  food  charts  issued  by  the  Association  for  Improving  the  Condition  of 
the  Poor,  New  York  City. 


As  Sherman  points  out,  there  are  "  large  discrepancies  between 
nutritive  value  and  market  cost,  and  correspondingly  ample  oppor- 
tunity for  the  exercise  of  true  economy  in  the  choice  of  food  ma- 
terials "  (see  Fig.  14). 


32  HOME  AND  COMMUNITY  HYGIENE 

The  need  for  economy  in  peace  as  well  as  in  war  time  makes 
the  following  rules  by  Lusk  very  helpful : 

Rules  of  Saving  and  Safety 

1.  Let  no  family  (of  five  persons)  buy  meat  until  it  has  bought  three 
quarts  of  milk,  the  cheapest  protein  food.  Farmers  should  be  urged  to 
meet  this  demand. 

2.  Save  the  cream  and  butter  and  eat  oleomargarine  and  vegetable 
oils.  Olive  oil  or  cottonseed  oil,  taken  with  cabbage,  lettuce,  or  beet-tops, 
is  excellent  food,  in  many  ways  imitating  milk. 

3.  Eat  meat  sparingly,  rich  and  poor,  laborer  and  indolent  alike.  Meat 
does  not  increase  the  muscular  power.  When  a  person  is  exposed  to  great 
cold,  meat  may  be  recommended,  for  it  warms  the  body  more  tlian  any 
other  food.  In  hot  weather,  for  the  same  reason,  it  causes  increased 
sweating  and  discomfort.  In  general,  twice  as  much  meat  is  used  as  is 
now  right,  for  to  produce  meat  requires,  much  fodder  which  might  be  better 
used  for  milk  production. 

4.  Eat  corn  bread.  It  saved  our  New  England  ancestors  from  starva- 
tion.   If  we  eat  it,  we  can  send  wheat  to  France.     Eat  oatmeal. 

5.  Drink  no  alcohol.  In  many  families  10  per  cent,  of  the  income  is 
spent  for  drink,  or  a  sum  which,  if  spent  for  real  food,  would  greatly  im- 
prove the  welfare  of  the  family. 

6.  Eat  corn  syrup  on  cereals.  It  will  save  the  sugar.  Eat  raisin.3  in 
rice  pudding,  for  raisins  contain  sugar. 

7.  Eat  fresh  fish. 

8.  Eat  fruit  and  vegetables. 

A  woman  to  whom  the  scientific  planning  of  meals  is  a  new 
thing  worked  over  the  problem  for  awhile,  and  then  said:  "It's 
just  like  putting  together  a  picture  puzzle  or  a  dissected  map.  You 
can't  ever  learn  it  by  heart,  though,  because  the  pieces  keep  chang- 
ing in  size  and  shape.  And  you've  always  got  to  get  them  all  back 
m  to  make  the  same  size  and  shape  picture  you  had  before.  The 
piece  that  was  potato  turns  to  rice,  and  then  you've  got  to  add 
minerals  and  vitamines  and  something  to  go  with  the  meats,  be- 
cause rice  is  an  acid-former,  too.  And  to  squeeze  them  in,  some- 
thing else  has  to  be  changed.  Even  so,  you  could  fit  them  all  in,  if 
the  seasons  and  markets  didn't  limit  you  so.  Strawberries  would 
fit  here — but  they  cost  fifty  cents  a  quart,  and  besides,  they  give 
John  hives.  For  there  are  always  family  peculiarities  to  consider, 
and  just  as  soon  as  you  decide  that  griddle  cakes  would  about  fit  that 
place,  you  remember  Aunt  Lucy's  indigestion.  It's  all  interesting, 
but  terribly  hard.  Of  course,"  thoughtfully,  "  if  I  work  at  it  long 
enough  it  would  be  hard  still,  but  it  might  be  terribly  interesting." 


FOOD  33 

PROBLEMS 

1.  An  average  pei'son  (150  pounds)  uses  70  calories  per  sleeping  and 
77  per  waking  hour.  Compute  the  24-hour  needs  of  one  who  works  8  hours 
at  work  demanding  extra  calories  per  hour:  typist,  25.;  housemaid,  80  to 
150;  laundress,  125  to  200;  tailor,  45;  shoemaker,  90;  carpenter,  100  to 
160;  stonemason,  300;  and  sawyer,  375. 

2.  Americans  eat  twice  as  much  meat  as  the  French  and  one  and  a 
half  times  as  much  as  the  English.  Give  three  reasons  why  we  should 
change  in  this  respect. 

3.  A  carpenter  is  supposed  to  need  3100  calories  a  day,  a  shoemaker 
2510.  If  circumstances  should  confine  them  to  milk  alone  for  a  temporary 
diet,  how  much  milk  would  each  need? 

4.  A  person  of  average  weight  uses  175  calories  in  walking  three 
miles  per  hour.  If  he  walks  nine  miles  at  that  rate,  how  many  calories 
does  he  use  up  ? 

If  his  food  costs  two  cents  a  hundred  calories,  would  it  be  cheaper  -for 
him  to  pay  the  five-cent  trolley  fare  or  buy  the  extra  food  needed? 

ADULTERATION  OF  FOODS    (AND  DRUGS ) 

A  dozen  years  ago  the  United  States  passed  a  Pure  Food  and 
Drugs  Act  which  deals  mainly  with  the  adulteration  of  foods. 
How  necessary  such  a  ruling  was  is  indicated  by  the  percentage  of 
adulteration  reported  at  that  time  by  three  of  the  various  food  and 
drug  workers  in  different  cities.     One  found 

40  per  cent,  of  over  700  samples  adulterated;   another 

41  per  cent,  of  over  500  samples;   and  a  third 
60  per  cent,  of  over  500  samples. 

Adulteration  Defined. — Adulteration  is  defined  in  several  dif- 
ferent ways  in  this  Act : 

( 1 )  "If  any  substance  has  been  mixed  or  packed  with  it  to  reduce  or 
lower  or  injuriously  affect  its  quality  or  strength." 

(2)  "If  any  substance  has  been  substituted  wholly  or  in  part  for  the 
article." 

(3)  "If  any  valuable  constituent  of  the  article  has  been  wholly  or  in 
part  abstracted." 

(4)  "If  it  is  mixed,  colored,  powdered,  coated,  or  stained  in  any  manner 
whereby  damage  or  inferiority  is  concealed." 

(5)  "If  it  contains  any  poisonous  or  other  added  deleterious  ingredi- 
ent which  may  render  such  article  injurious  to  health." 

(6)  "If  it  consists  in  whole  or  in  part  of  a  filthy,  decomposed,  or  putrid 
animal  or  vegetable  substance  or  any  portion  of  an  animal  unfit  for  food, 
whether  manufactured  or  not,  or  if  it  is  the  product  of  a  diseased  animal 
or  one  that  has  died  otherwise  than  by  slaughter." 

3 


34 


HOME  AND  COMMUNITY  HYGIENE 


Following  is  a  list  of  adulterations,  which  belong  under  one  or 
more  of  these  six  headings  Just  where,  it  may  interest  the  reader 
to  decide : 


Substance  Adulterant  Remarks 

Cocoa  or  chocolate Cocoa  shells 

Maple  sugar Glucose 

Oleomargarine Coloring  Sold  as  butter 

Flour    Talc,  gypsum 

Olive  oil Corn  oil,  cottonseed  oil 

Gum.  drops Paraffin 

Sausage    Cereals 

Cane  sugar   Saccharin  A     coal     tar     product 

( sweet,    but    lacking- 
food  value) 

Gandy Clay  or  "terra  alba" 

Whole  milk Skim  milk 

Cream Gelatin 

Chocolate Cocoa  butter  subtracted 

Green  peas    Colored  by  copper  sul- 
phate 

Jellies Turnips,  squash 

Tea    Once-used  tea  leaves 

Cheese    Lard.^"   bean   meal,   po- 
tato, bread 

Coffee    Cereals,     acorns,     date- 
pits,  red  slate 

Condensed  milk   Cane  sugar  added  to  re-  Less     suitable    for    in- 

place  fats  subtracted  fants 

Whole  coffee  beans ....  Molded  cereal  paste 

Special  coffees Caffein   extracted 

Cocoa    Starch,  clay,  brick  dust, 

mutton  oil 

Molasses    Glucose  Lightens  color  to  high- 

er grade  appearance 

Honey Glucose  with  pollen  Pollen  is  found  in  bee- 

collected   honey 

Flour    Alum,      nitrogen      per-  Passes   as    first   grade ; 

oxide  flour    retains   poison- 

ous     nitrogen      com- 
pounds 

Nuts  and  fruits Whitened     by     sulphur  Injurious  sulphur  com- 

fumes  pounds     retained     by 

fruits,   kernels 

Milk    Formaldehyde  To  defer  souring 

"Lard  is  the  only  common  adulterant  in  this  country;  it  would  seem 
as  if  the  labelling  of  cheese  should  be  more  definite. 


FOOD  35 

Substance  Adulterant  Remarks 

Oysters    Fattened  in  water  con- 
taining   sewage 

Figs    Worms  and  their  wastes         These  worms  are  larvae 

of  insects  which  fer- 
tilize the  fig  when 
they  come  to  deposit 


Meat  Chemicals,  such  as  salt-         To  bring  back  red  color 

peter 

Table  salt   Starch  To  prevent  caking 

Meat  extracts Plant  extracts  Though    cheaper,    some 

plant  extracts  (e.  g., 
yeast )  add  valuable 
vitamines,  yet  they 
are  considered  adul- 
terants unless  prop- 
erly labelled 

Butter  Substitutes. — Oleomargarine  is,  according  to  the  United 
States  rulings,  the  term  to  be  applied  to  butter  or  substitutes  for 
butter  containing  fats  other  than  cream.  Numerous  other  fats  are 
used  in  such  butter  substitutes:  beef  suet,  lard,  cottonseed  oil,  nut 
oils.  The  prejudice  against  the  use  of  such  oils  or  fats  is  most  un- 
reasoning and  unreasonable,  as  sufficient  vitamines  can  be  supplied 
in  such  necessary  articles  of  the  diet  as  milk  and  vegetables.  In 
forms  other  than  butter,  for  baking  and  cooking  especially,  they  have 
found  their  way  into  all  homes.  They  are  as  rich  in  fuel  value  and 
as  easily  digested  as  butter;  these  substitute  fats  and  oils  are  col- 
lected and  refined  in  a  much  cleaner  way  than  butter  fat  usually 
is;  they  usually  decompose  less  rapidly,  and  differ  from  butter  not 
in  being  artificially  colored,  but  in  needing  a  little  more  coloring  to 
give  the  customary  appearance.  The  only  legitimate  reason  for 
objection  is  that  they  are  sold  as  butter,  coloring  tending  to  help 
deceive.  The  remedy  found  in  our  national  pure  food  law  demanding 
a  correct  statement  on  the  label  for  all  food  sold  in  interstate  com- 
merce; does  not  protect  the  consumer  against  such  adulterated  foods 
if  produced  within  his  own  State.  The  old  ruling  prohibiting  the  sale 
of  colored  oleomargarines  without  a  special  license  serves  no  good 
purpose  now,  but  only  tends  to  keep  up  the  price  of  both  butter  and 
its  substitutes. 

Drug  Adulterations. — ^In  drugs  the  worst  possible  adulteration 
has  been  found.  Soon  after  the  passage  of  this  Food  and  Drugs 
Act,  one  firm  was  convicted  of  adulterating  two  drugs  sold  in  pow- 


36 


HOME  AND  COMMUNITY  HYGIENE 


der  form,  in  which  one  powder  was  composed  of  ground-up  olive 
stones  and  the  second  of  finely-pulverized  burlap  ! 

Alcohol. — Large  amounts  of  alcohol  have  been  sold  as  medi- 
cines ;  soothing  syrup,  cold  mixtures,  headache  medicines,  and  tonics 
have  often  covered  a  brisk  sale  of  spirituous  liquors — and  the  unsus- 
pecting, as  well  as  the  confirrred  alcoholics,  have  been  injured 
thereby. 


100 


COi  /ovi'e  J  X  \  ho[y\(Ar\o^ 


o  /    beer 


+ 


(fl55 


Fig.   15. 


-To  offeet  the  "drug"  character  of  alcohol,  some  advance  its  food  value, 
figure  shows  it  to  be  a  very  high-priced  food. 


Thia 


That  alcohol  has  a  slight  value  in  calories  (Fig.  15)  has  been 
used  as  an  argument  against  classifying  it  as  an  adulterant  (e.g'., 
in  candies)  or  as  a  harmful  drug  i^e.g.,  in  patent  medicines,  some 
of  which,  before  the  present  laws,  were  66  per  cent,  alcohol). 
Though  this  may  seem  primarily  a  question  of  personal  hygiene,  its 
relation  to  community  interest  is  obvious.  Alcohol  predisposes  to 
8uch  industrial  diseases  as  lead  poisoning;  it  increases  the  accident 
list  (accident  policies  are  not  paid  to  claimants  shown  to  have  been 
intoxicated)  ;  it  increases  the  susceptibility  to  general  disease  (life 


FOOD 


37 


insurance  rates  are  sometimes  increased  for  alcoholic  risks;  it  is 
the  greatest  source  of  misery  (moral,  social,  and  economic)  known. 
See  p.  321.  It  increases  the  crimes  against  property  and  indi- 
viduals, including  illegitimacy,  non-support  of  dependents,  and  the 
perpetuation  of  feeble-minded,  insane,  and  diseased  offspring;  all 
this  makes  it  in  every  respect  a  community  problem.  Someone  has 
said  that  if  alcohol  were  a  new  drug  introduced  from  abroad,  its 
importation  would  long  since  have  been  forbidden  (see  Fig.  110). 

Now  the  percentage  of  alcohol  and  similar  irritants  and  poisons 
must  be  printed  on  the  label  of  patent  medicines  and  similar  prep- 
arations. (Certain  drugs  it  is,  of  course,  still  impossible  to  buy 
without  the  necessary  physician's  order.) 

Labels. — Many  of  the  adulterations  of  the  types  listed  in  the 
table  on  page  34  are  not  illegal,  if  the  label  indicates  the  fact 
and  the  amount  of  adulteration.  A  little  search  among  the  pack- 
age articles  sold  at  your  grocer's  will  reveal  such  labels  as  these : 


Apple  Jelly 
(containing  12  per  cent,  glucose) 


or 


Citro — Marmalade 
(containing  .1  per  cent,  benzoate  of  soda) 


Injurious  Adulterants. — The  government  has  not  fully  pro- 
tected its  people,  if  correct  labels  are  the  only  thing  insisted  upon. 
The  unscrupulous  hotel  keeper  or  boarding  house  manager  might 
use  inferior  food  or  food  containing  injurious  preservatives,  while 
charging  for  safe,  first-rate  materials.  Or  the  ignorant  and  illiterate 
might  use  objectionable  preservatives  in  one  or  more  foods  for  a 
long  period  without  knowing  the  cumulative  effect  of  the  chemical 
thus  eaten. 

The  pure  food  and  drug  laws  are  meant  to  insure  three  things : 

1.  The  nutritive  value  the  name  indicates  {e.g.,  sugar  and  not 
non-utilizable  saccharin)  ; 

2.  Full  money  value  {e.g.,  meat  and  not  cereal  in  sausage) ; 

3.  Absence  of  deleterious  substances  of  several  types:  (a)  in- 
jurious bacteria,  such  as  tuberculosis  in  meat;  (&)   decomposition 


38  HOME  AND  COMMUNITY  HYGIENE 

products  formed  by  bacteria  and  other  micro-organisms;  and 
(c)  harmful  drugs,  used  to  cover,  delay,  or  inhibit  beginning 
decomposition. 

Difficulties  in  Interpretation.- — The  difficulties  met  in  inter- 
preting the  provisions  of  the  food  and  drug  regulations  act  are  un- 
guessed  by  most  of  us.    Some  of  these  may  be  briefly  described : 

1.  Decomposition  is  but  a  relative  term:  a  stage  objectionable  in 
one  cheese  is  the  one  most  desired  in  another ;  meat  that  has  spoiled 
for  one  person  is  but  "  gamy  "  to  another  who  prefers  having  his 
domestic  fowls  suggest  the  ranker  flavor  of  a  favorite  game  bird. 
Other  foods  sold  in  the  sour-krout  stage  would  be  thrown  away 
uneaten. 

2.  Chemicals  harmless  in  large  amounts  may  be  harmful  in 
small  amounts  if  taken  continuously.  To  illustrate:  rather  large 
amounts  of  lead  (e.g.,  sugar  of  lead)  may  be  taken  in  a  single  dose 
without  harm,  as  most  of  it  is  eliminated  and  but  a  tiny  part  ab- 
sorbed. But  if  that  same  dose  had  been  given  daily  in  minute 
amounts,  it  would  all  be  absorbed  and  serious  lead  poisoning  would 
finally  result. 

3.  Chemicals  harmful  in  large  amounts  may  not  be  harmful  in 
small  amounts.  For  example,  the  strong  poison,  hydrocyanic  acid, 
is  harmless  in  small  amounts,  because  it  unites  with  sulphur,  mak- 
ing a  harmless  sulphur  compound.  Benzoic  acid,  hydrochloric  acid, 
table  salt,  and  probably  alcohol  and  acetic  acid  are  similarly  poison- 
ous in  large  amounts,  but  comparatively  harmless  in  small  amounts. 
While  it  is  probable  that  most  poisons  fatal  or  injurious  in  large 
amounts  are  also  dangerous  in  small  amounts,  if  continued  long 
enough,  the  second  and  third  difficulties  make  decision  regarding 
certain  drugs  very  difficult.  That  a  feeding  squad  did  not  show 
for  a  given  chemical  any  evil  results  in  several  weeks  or  even  months 
does  not  positively  indicate  what  the  cumulative  effects  for  a  life- 
time would  be.  Much  of  the  recent  discussion  regarding  the  use 
of  certain  chemicals,  such  as  benzoate  of  soda,  as  food  preservatives 
has  been  due  to  honest  differences  of  opinion  based  on  just  such 
difficulties  as  the  last  two. 

Part  of  the  difficulty  could  be  solved  by  considering,  instead,  the 
reason  for  the  addition  of  such  chemicals.  The  general  success  of 
the  housewife  in  canning  and  similar  methods  of  food  preservation, 
shows  that  commercial  processes,  with  their  efficient  apparatus,  do 


FOOD 


39 


Fig.  16. — Adulteration  of  drugs  is  often  detected  by  the  microscope.  The  left-hand 
figures  show  typical  parts  of  true  horehound.  1,  flower  hairs;  2,  pollen  grains;  3  and  4, 
glandular  hairs.     Characteristic  parts  of  false  horehound  are  shown  on  the  right. 


40 


HOME  AND  COMMUNITY  HYGIENE 


not  need  to  use  such  preservatives  to  make  foods  keep.  If,  as  often 
happens,  these  preservatives  are  used  to  mask  poor  material,  to  re- 
move signs  of  decomposition  (to  harden  fibres  and  tissues,  to 
brighten  the  changing  color),  the  consumer  is  paying  for  first-class 
material  and  receiving  third-class  substitutes — losing  usually  in 
both  money  and  nutritive  values. 

Methods  of  Proving  Adulteration. — A  fourth  difficulty  is 
sometimes  found  in  proving  the  type  or  amount  of  adulteration. 
All  kinds  of  aids  are  utilized  by  the  government  experts ;  and  while 


Fig.  17. — That  this  sample  of  pepper  contained  foreign  or  adulterating  material  was 
shown  by  the  microscope.  B  and  C  are  characteristic  cells  of  pepper  seed  coats  and  hulls; 
but  A  is  from  the  stone  of  the  olive,  S  is  corn  starch,  and  L  shows  calcium  sulphate  crystals. 


a  detailed  knowledge  of  chemistry  is  often  absolutely  necessary, 
there  are  many  tests  so  simple  that  a  high  school  student  could  use 
them.  For  example,  starchy  materials  are  often  used  for  adulterat- 
ing cocoa  and  coffee;  starch  turns  blue  in  the  presence  of  iodine, 
and  weak  dilutions  of  starch-containing  substances,  especially  if 
boiled,  will  give  a  blue  to  black  color  when  iodine  is  added.  Some- 
times the  simple  question  of  the  solubility  of  a  substance — soluble 
or  not  soluble — in  water  or  in  alcohol  proves  the  presence  or  absence 
of  adulteration.  The  microscope  is,  for  many  substances,  the 
simplest  way  of  settling  the  question  of  adulteration.  The  cells 
composing  plant  and  animal  tissues  have  their  characteristic  shapes, 
sizes,  markings,  or  contents.     Some  of  these  are  so  marked  or  con- 


FOOD  41 

stant  that  a  bit  of  crushed  leaf  will  not  fail  to  show  the  star-like 
hairs  that  cover  the  leaf  surface,  or  ground  seeds  or  stems  of  a 
given  plant  will  alwaysi  contain  cells  or  crystals  of  a  certain  shape, 
granules  of  unmistakable  contour,  etc.  (Fig.  16).  The  accompanying 
illustration  shows  varied  types  of  cells  found  in  one  sample  of  black 
pepper  which  came  from  the  sources  indicated  and  are  never  found 
in  pepper  (Fig.  17).  The  specific  gravity  of  substances  is  easily 
determined  and  has  proven  a  helpful  guide.  Boiling  and  freezing 
points  vary  with  salts,  etc.,  in  solution,  so  tests  of  that  kind  are 
often  used  to  see  whether  valuable  substances  have  been  subtracted 
or  undesirable  or  cheaper  ones  added  to  increase  bulk  or  weight. 
The  polariscope  "  is  also  useful. 

Chemicals  Not  Necessary  in  Canning  Processes, — Claims 
often  made  by  commercial  food  producers  to  justify  their  use  of 
chemicals  in  food  preservation  are  (l)that  the  same  process  has 
long  been  used  in  the  home,  e.g.,  greening  pickles  in  a  copper 
kettle;  (2)  that  the  same  chemical  is  formed  naturally  in  accepted 
processes,  e.g.,  formaldehyde  in  very  small  amounts  may  be  formed 
in  prolonged  heating  of  sugary  substances;  and  (3)  that  the  same 
chemical  is  used  in  sickness,  e.g.,  salicylic  acid  in  treating  rheu- 
matism. As  Harrington  points  out,  drugs  having  a  powerful  in- 
fluence for  good  in  morbid  states  may  exert  an  equal  degree  of 
influence  for  harm  in  health.  We  must  also  remember  that  the 
procedure  is  not  designed  to  benefit  the  consumer,  but  the  producer; 
and  without  legislation  preservatives  are  doubtless  added  too  freely 
and  too  little  attention  is  paid  to  metallic  poisons.  While  there  is 
little  accumulated  evidence  that  serious  illness  results  from  the 
copper  greening  of  tea  and  green  vegetables,  or  tin  foil  wrappers 
(chocolate,  cream  cheese),  constant  use  of  such  substances  may  have 
a  deleterious  effect.  Harrington  warns  against  the  daily  use  of 
soft  drinks  from  bottles  having  lead  stoppers.  Tin  in  poisonous 
forms  is  rarely  found  in  foods  (see  p.  58). 

Small  amounts  of  certain  preservatives  are  allowed  in  dried 
fruits,  such  as  sulphur  for  dried  apples  and  creosote  for  hams. 

^  It  is  a  special  kind  of  instrument,  resembling  an  ordinary  microscope. 
The  substance  to  be  tested  is  held  in  a  special  container,  and  light  passed 
through  that  substance  shows  certain  changes  in  direction.  This  deflec- 
tion varies  greatly,  for  example,  in  the  sugars,  varying  not  only  with  the 
kindi  of  sugar,  but  with  the  percentage  in  the  solution. 


42  HOME  AND  COMMUNITY  HYGIENE 

PROBLEMS 

1.  Has  your  own  city  or  state  any  rulings  regarding  adulteration, 
labelling  and  misbranding  of  foods?  Does  it  compel  correct  labelling  of 
goods  not  in  "original  packages,"  such  as  storage  eggs,  Mocha  coffee,  arrow- 
root crackers? 

2.  Make  a  list  of  the  articles  for  sale  by  your  grocer  which  do  give 
the  names  or  amount  of  preservative  added.     The  adulterants  added. 

3.  Starch  is  mixed  with  yeast  to  make  a  drier,  better-keeping  cake, 
yet  a  recent  United  States  ruling  makes  starch  in  yeast  cakes  an  adulterant, 
unless  they  are  so  labelled.    What  do  your  yeast  cakes  say? 

4.  How  many  of  your  foods  are  not  protected  by  the  United  States 
rulings?     By  any  State  ruling? 

5.  Can  milk  be  considered  as  under  the  interstate  law  when  it  is  sold 
outside  the  State ;  e.g.,  from  New  Jersey  farms  into  New  York  City  ?  Why 
does  the  United  States  Government  not,  then,  control  such  milk  supplies? 

6.  The  Federal  Government  considers  "  widely  advertised  or  generally 
sold"  articles  within  its  province,  even  though  there  is  no  record  of  inter- 
state sale;  support  this  view.  Federal  regulations  have  established  for 
interstate  trade  the  following  standard  containers :  ( 1 )  lime  barrels,  ( 2 ) 
barrels  for  "fruits,  vegetables  and  other  dry  commodities,"  and  ( 3 )  baskets 
for  "grapes  and  other  fruits  and  vegetables."  The  regulations  require  all 
packages  of  food  to  be  marked  with  their  net  weights,  measure  or  numerical 
count.  What  foods  produced  in  your  State  and  sold  in  your  locality  are 
not  similarly  protected  by  State  regulations?  (Copies  of  Federal  and 
State  rulings  can  be  obtained  from  the  Bureau  of  Standards  at  Wash- 
ington or  from  your  own  State  departments  of  weights  and  measures.) 
Are  you  protected  against  dishonest  loose  weights  by  your  own  State 
regulations  ? 

7.  Many  people  in  New  York  City  have  been  using  with  loud  praise 
a  pleasant-tasting  tooth  wash,  which  the  Federal  Government  has  recently 
investigated  and  condemned.  How  can  you  be  sure  you,  in  your  State, 
are  not  using  this  tooth  wash?  Is  the  Federal  Government  right  in  exer- 
cising authority  over  "widely  advertised"  articles  as  well  as  over  articles 
actually  in  interstate  trade? 

8.  What  are  the  economic  losses  to  the  consumer  and  to  the  nation 
resulting  from  food  adulteration? 

9.  How  many  patent  medicines  sold  in  your  town  contain  harmful 
substances  ?  Does  your  State  answer  questions  covering  suspected  medicines  ? 

10.  The  United  States  Department  of  Agriculture  issues  periodically 
pamphlets  called  service  and  regulatory  announcements.  These  contain 
(1)  standards  to  which  substances  must  conform  and  (2)  short  descrip- 
tions of  foods  and  drugs  which  they  have  investigated  and  condemned. 
Interesting  titles  from  the  1917  reports  are  horehound  substitutes,  tuna 
fish,  beans  containing  prussic  acid  denied  entry,  adulteration  of  canned 
pork  and  beans,  and  adulteration  of  condensed  milk  and  misbranding  of 
coca-cola,  vinegar,  gelatin  pills,  and  rheumatic  remedies. 

The  findings  include  destruction  of  adulterated  articles,  and  sometimes 
fines  including  costs.  Sometimes  on  filing  a  bond  for  a  considerable  sum, 
such  as  $1000,  the  defendant  is  allowed  to  re-label  such  products  properly. 
Ask  your  school  or  library  to  send  for  the  1917  and  later  announcements, 
and  see  if  you  are  using  condemned  articles  not  salable  outside  your  State. 


FOOD  43 

MEAT  INSPECTION 

In  the  United  States  (under  pre-war  conditions)  considerably 
over  100,000,000  cattle,  sheep,  goats,  and  swine  are  slaughtered 
yearly.  Only  about  60  per  cent,  of  these  are  killed  in  the  slaughter 
houses  of  firms  concerned  in  interstate  or  foreign  trade,  and  so 
come  under  federal  control.  Government  supervision  began  in  1906, 
and  over  three  million  dollars  are  appropriated  annually  to  cover 
the  inspection  of  meat  and  meat  food  products.  There  are  in  the 
United  States  at  least  875  packing  houses  and  several  hundred 
process  establishments  where  meat  or  meat  foods  are  produced  or 
prepared,  concerned  in  interstate  and  foreign  meat  trade  and  so 
subject  to  federal  inspection.  Some  idea  of  the  amount  of  work 
done  by  the  federal  government  is  gained  on  reading  that  inspection 
is  conducted  in  244  cities,  and  that  the  total  number  of  meat  and 
meat  food  establishments  inspected  is  over  3000. 

Adulteration, — Eegulations  concerning  adulteration  are  mainly 
limited  to  such  restrictions  as  the  following  concerning  meat  food 
products :  sausage  must  not  contain  more  than  2  per  cent,  cereal  or 
more  than  3  per  cent,  water,  unless  it  is  labelled  "  sausage  and  cereal 
and  water  " ;  chemicals  used  for  color  changes,  as  in  corned  beef,  are 
limited  in  kind  and  in  amount ;  the  substitution  of  veal,  tuna  fish, 
etc.,  for  chicken  must  be  indicated  by  the  label;  and  the  various 
extract  products  (e.g.,  meat  juice,  meat  extract,"  and  fluid  meat 
extracts)  must  be  labelled  to  conform  with  the  percentage  of  total 
solids,  and  to  indicate  such  additions  as  table  salt  and  plant  extracts. 

Reasons  for  Federal  Regulations. — These  regulations  are 
mainly  designed  to  protect  man  against  pathogenic  or  destructive 
organisms.  Such  organisms  may  cause  definite  disease  in  man  or 
they  may  injure  him  less  directly  by  causing  decomposition  changes 
in  the  meat. 

The  bacterial  diseases  which  may  be  transferred  to  man  through 
meat  eating  are  mainly  glanders   (horse  "),  tuberculosis    (cattle, 

12  Extracts  have  little  focwi  value.  Most  of  the  protein  is  left  in  the 
residue,  the  protein  in  the  extract  never  exceeding  7  to  13  per  cent.  They 
are  stimulating  rather  than  nutritive.  The  popular  bouillon  cubes  are 
commonly  50  per  cent,  to  75  per  cent,  common  table  salt.  Plant  extracts 
are  sometimes  present  as  adulterants;  they  may  be  valuable  as  sources  of 
vitamines. 

I'At  present  (May,  1918),  horse  meat  is  being  sold  in  New  York  City. 
About  twenty- four  horses  a  week  are  sold  in  one  section  of  Brooklyn;  in 
that  section  there  are  nine  stores  selling  nothing  but  horse  meat. 


AA  HOME  AND  COMMUNITY  HYGIENE 

swine),  anthrax  (cattle),  and  foot-and-mouth  disease  (cattle,, 
sheep).  Some  authorities  look  with  suspicion  upon  Texas  fever 
(cattle).  Malta  fever  in  goats,  which  may  be  transmitted  to  man,  is 
not  common  in  the  United  States.  Other  disease-causing  organ- 
isms which  are  transferred  to  man  from  affected  cattle  are  tape- 
worm from  cattle  and  swine,  and  trichina  from  swine. 

Other  organisms  which  do  not  cause  definite  diseases  in  the  ani- 
mals themselves,  though  they  may  be  constant  inhabitants  of  the 
alimentary  canal,  may  cause  disease  in  man.  The  most  widely 
known  organisms  of  this  kind  are  Bacillus  enteritidis,  B.  'paraty- 
phosus,  and  B.  hotulinus  and  the  relatives  of  B.  coli.  Such  organ- 
isms may  get  on  meat  handled  in  an  unsanitary  way  {e.g.,  killed  in 
rooms  containing  live  animals  or  soiled  with  animal  excreta,  or  by 
contact  with  flies  or  rats  from  cattle  pens  or  refuse  heaps).  These 
organisms  usually  cause  intestinal  disturbances,  either  because  of 
their  multiplication  in  the  human  int^tine  (B.  enteritidis  and  B. 
paratyphosus)  or  because  they  form  poisonous  substances, true  toxins 
(G).  True  toxins  are  formed  by  B.  hotulinus  (botulism).  All  the 
above  effects  were  formerly  loosely  termed  "ptomaine  poisoning." 

While,  as  just  stated,  these  poisonous  substances  usually 
cause  stomach  or  intestinal  irritation  (vomiting,  diarrhoea),  their 
effects  vary  somewhat  with  the  individual,  and  may  be  manifested 
in  heart  or  nervous  derangements,  including  dizziness,  delirium, 
partial  paralysis,  collapse  or  death.  Such  disturbances  are  more 
common  as  a  result  of  eating  veal,  fish,  poultr}^  or  oysters,  thougli 
they  may  be  caused  by  pork  or  mussels. 

Cooking  often  destroys  the  accumulated  poisons.  A'eal,  pork, 
and  fish  should  always  we  well  cooked.  Boiling  destroys  the  toxin  of 
B.  hotulinus.  Suspicious-looking  or  bad-smelling  meats,  fish,  etc., 
should  be  avoided,  as  cooking  is  not  a  positive  safeguard. 

Bob  Veal. — Very  young  veal  is  commonly  spoken  of  as  "  bob 
veal."  The  maximum  age  of  calves  described  by  that  term  is  4  to 
6  weeks.  Many  claim  it  is  dangerous  to  eat  veal  of  that  early  age, 
though  there  seems  to  be  no  chemical  or  other  test  to  distinguish  bob 
veal  from  older  veal.  Experiments  by  Fish  at  Cornell  University 
in  which  very  young  veal  was  given  to  people  varpng  in  age  from 
three  to  seventy-five  years,  indicate  that  the  meat  of  sound  calves  is 
not  harmful.  The  ages  were  kept  secret,  and  the  recipients  voted 
on  the  respective  qualities  of  the  meat  given  them  at  varying  inter- 
vals, and  the  heaviest  ^•ote  fell  to  three-day  old  veal !    This  is  sup- 


FOOD  45 

ported  by  later  work  by  Langworthy  and  his  associates.  In  Europe 
bob  veal  is  not  looked  upon  -with  suspicion.  Veal  decomposes  more 
readily  than  beef.  Young  calves  are  often  infected  with  diarrhoea 
and  other  infections.  The  difficulties  experienced  in  eating  bob 
veal,  or  even  older  veal,  are  probably  due  to  these  conditions.  The 
age  at  which  a  farmer  is  allowed  to  sell  his  calf  affects  the  milk 
production  directly.  It  is,  therefore,  important  economically  that 
the  value  of  bob  veal  should  be  recognized. 

Storage. — If  the  meat  is  kept  below  freezing,  little  bacterial 
invasion  and  decomposition^*  can  take  place.  Meat  is,  therefore, 
rushed  through  the  preliminar}^  processes  as  promptly  as  possible, 
and  in  large  packing  houses  the  carcasses  may  reach  the  chilling 
room  within  half  an  hour  after  the  death  of  the  animal.  It  is  later 
put  into  cold  storage  vaults  and  kept  until  sold  or  used  (see  p.  53). 

Regulations. — The  regulations  aim  to  insure  safe  meat  to  the 
consumer.  They  are  framed  to  eliminate  diseased  meat,  to  avoid  the 
infection  of  good  meat,  and  to  prevent  breaking  of  these  rules  by  un- 
reliable producers.  Among  the  many  regulations  are  the  following : 
Xo  animals  must  be  killed  before  the  United  States  inspector  is 
ready  for  inspection;  the  inspector  must  be  admitted  at  any  hour 
of  the  day  or  night ;  suspicious  carcasses  must  be  shunted  off  out  of 
the  regular  line  of  animals  "  and  specially  examined  at  the  end  of 
the  day,  to  avoid  contaminating  knives,  etc. ;  condemned  carcasses 
must  be  taken  at  once  to  receptacles  where  they  are  treated  with  hot 
steam  until  they  are  unfit  for  food,  or  must  be  dumped  into  tanks  for 
making  fertilizer,  etc. ;  before  the  carcass  is  passed  by  the  inspec- 
tor, organs  likely  to  show  infection  are  specially  examined,  e.g., 
lungs  and  the  glands  near  the  intestine  for  tuberculosis.  Knives 
used  on  suspected  carcasses  must  be  sterilized  with  hot  steam  before 

"While  most  of  us  rarely  get  meat  in  an  advanced  state  of  decompo- 
sition, the  following  characteristics  given  by  H.  B.  Wood  may  be  helpful. 
Spoiled  beef  is  wet,  flabby,  pink  or  purple  (iridescent  lines  in  beef  do  not 
denote  decomposition),  with  a  distinct  foul  odor;  spoiled  veal  is  soft, 
mushy,  sticky,  with  a  very  red  tinge,  the  fat  grayish  lead  color ;  the  fat 
of  spoiled  pork  is  soft  and  yellow,  not  pure  white ;  stale  poultry  is  flabby, 
bluish-green  on  the  crop,  the  skin  is  easily  pulled  apart,  and  the  abdomen 
has  a  bad  odor ;  fresh  fish  have  red  gills,  moist  bright  scales,  clear  eyes, 
and  firm  rigid  bodies;  and  shellfish  shells  should  close  when  touched  or 
put  into  water. 

^'  The  large  animals  are  all  dressed,  etc.,  while  suspended  from  over- 
head tracks  or  runways.  No  animal  can  be  taken  from  the  isolated  suspect 
runway  without  the  inspector's  permission. 


46  HOME  AND  COMMUNITY  HYGIENE 

being  used  again ;  passed  carcasses  must  be  stamped  plainly,  "U,  S. 
inspected  and  passed/'  and  condemned  meat  must  be  marked, 
"  U.  S.  inspected  and  condemned,"  or  made  unsalable  by  strong 
dyes,  etc.  Meat  products  (lard,  oleo,  sausages,  casings  for  ham 
or  sausages,  etc.,  made  from  intestinal  membranes,  etc.)  must 
be  produced  under  the  same  sanitary  restrictions  as  the  meat  itself. 

The  building  itself  must  reach  certain  sanitary  standards,  and 
the  necessary  permit  will  not  be  supplied  to  firms  who  do  not  reach 
a  minimum  standard  with  regard  to  the  lighting,  plumbing,  run- 
ning water  of  good  quality,  water  wastes,  hot  water  for  hand  wash- 
ing, toilets,  dressing  rooms,  clean  clothes  for  workmen,  appliances 
for  sterilizing  buckets,  wheelbarrows,  knives,  tanks,  etc.,  accumula- 
tions of  refuse,  etc.,  and  the  control  of  dogs,  rats,  flies,  and  other 
vermin.  The  regulations  are  detailed  enough  to  include  such  dan- 
gerous but  all-too-common  practices  as  holding  meat  skewers  in  the 
mouth. 

Interstate  and  Foreign  Control. — Kailroads,  ferries  and  other 
interstate  conveyances  are  not  allowed  to  pass  meat  without  a 
government  certificate  or  showing  the  government  stamp;  vessels 
carrying  animals  or  meat  cannot  clear  for  foreign  ports  without  a 
federal  certificate.  All  meat  sent  to  foreign  ports  must  come  up  to 
the  United  States  standards,  unless  it  is  specially  prepared  according 
to  specifications  issued  by  the  foreign  buyer,  in  which  case  it  must 
conform  to  the  requirements  of  the  country  to  which  it  is  sent. 

Conditions  Abroad. — Abroad,  many  of  the  customs  and  regu- 
lations are  apparently  less  rigorous  than  full  protection  would  war- 
rant. Animals  "  dying  naturally "  are  the  perquisite  of  herders 
{e.g.,  in  Scotland),  and  strange  to  say,  little  trouble  from  such  meat 
is  reported.  Fish  causes  more  poisoning  abroad  than  in  this  coun- 
try, partly  because  more  fish  is  eaten  raw,  and  partly  due  to  the 
custom  among  dealers  of  keeping  fish  alive  in  small  tanks,  probably. 
Then,  too,  ice  is  less  generally  used  abroad;  it  is  no  uncommon 
sight  to  see  street  counters  covered  with  flat  trays  of  various  kinds  of 
fish  exposed  without  ice  or  covering  in  the  hottest  weather.  Over 
these  the  attendant  occasionally  turns  the  hose,  thus  distributing 
any  decay  organisms  that  may  chance  to  be  present.  Fish  that 
crushes  between  the  fingers  is  not  safe,  but  danger  may  attend  less 
complete  disintegration  (see  footnote,  p.  45). 

The  United  States  System. — The  United  States  has  a  very 


FOOD  47 

good  federal  system  of  meat  inspection,  Eecent  unjustified  state- 
ments have  tended  to  discredit  it.  Some  of  these  were  made  by  a 
few  ignorant  persons  seeking  self  advertisement  at  the  expense  of 
their  own  country,  and  derogatory  statements  concerning  the  inspec- 
tion service  which  got  into  print  were  afterward  retracted  by  such 
self-advertisers  or  proven  untrue  in  courts  of  law.  The  contradic- 
tions, unfortunately,  were  not  so  widely  circulated  or  read.  The  sec- 
ond set  of  derogatory  statements  originated  in  Germany  some  years 
before  the  war  in  an  effort  to  keep  out  American  meats,  and  so  pla- 
cate certain  agricultural  "interests  which  had  previously  been  treated 
poorly  in  other  legislative  enactments  in  Germany.  Under  pretense 
of  tuberculosis  and  trichina  dangers,  the  importation  of  American 
meats  was  reduced  to  a  minimum.  The  actual  figures  disprove  the 
contention,  however.  Out  of  over  8000  American  cattle  slaughtered 
and  examined  at  Hamburg  but  4  were  found  to  be  tubercular,  while 
out  of  the  same  number  of  native  German  cattle  640  were  found  to 
be  tubercular !  In  the  fifteen  years  following  the  exclusion  of 
American  pork,  there  were  in  Prussia  alone  over  3000  cases  and  over 
300  deaths  from  trichinosis,  40  per  cent,  of  which  was  traced  to  ani- 
mals declared  free  from  trichina.  At  that  same  time  in  the  United 
States  trichinae  were  found  in  but  2  per  cent,  of  over  2,000,000 
hogs,  and  the  total  of  human  cases  collected  for  30  years  amounted 
to  but  900  cases !  Also,  all  the  figures  available  indicate  that  meat 
raised  in  the  United  States  is  remarkably  free  from  tuberculosis 
when  compared  with  European  cattle,  where  the  figures  in  many  of 
the  European  countries  show  from  25  to  50  per  cent,  to  be  tuber- 
cular. This  relative  freedom  from  tuberculosis  in  the  United  States 
is  supported  by  the  high  repute  still  attaching  to  tuberculin  tests 
(G)  for  cattle. 

Experienced  veterinarians,  such  as  Moore,  who  are  familiar  with 
meat  inspection  here  and  abroad,  state  that  we  have  by  far  the  best 
system  of  meat  inspection.  The  one  change  they  all  suggest  is  less 
rigid  condemnation.  Diseased  areas  might  be  removed  and  de- 
stroyed, leaving  much  meat  safe  for  human  consumption.  We 
wholly  condemn,  however,  a  large  number  of  animals"  yearly  a 
good  part  of  which  might  be  sterilized  and  sold  as  second-grade 

18  In  1916  the  United  States  inspectors  inspected  and  passed  about 
62,000,000  animals ;  the  condemned  animals  numbered  nearly  275,000.  The 
Federal  inspectors  also  condemned  on  reinspection  nearly  18,000,000 
pounds  of  meat  or  meat  foods,  because  they  were  soured,  tainted,  etc. 


48  HOME  AND  COMMUNITY  HYGIENE 

meat.  It  would  be  a  little  tougher,  a  little  less  attractive  in  color, 
but  safe.  Much  of  it  might  be  made  up  into  chopped  meat  com- 
pounds, such  as  mince  meat,  nut-meat  loaf,  etc.  Much  meat,  such 
as  hams,  and  meat  foods,  such  as  sausages,  are  condemned  on  the 
reinspection  given  them.  We  do  not  realize  how  complete  the  in- 
spection is.  The  animals  themselves  are  subject  to  inspection  on 
the  trains  or  in  the  stock-yards ;  they  are  inspected  during  the  kill- 
ing process ;  meat  made  up  into  meat  foods  is  inspected  in  the  estab- 
lishment where  that  is  done,  and  the  finished  products  are  inspected. 
Such  goods  are  inspected  when  shipped,  and  on  their  arrival  at 
their  destination.  Meat  crossing  State  lines  may  be  shipped  in  bond 
to  its  final  destination,  e.g.,  jSTew  York  City,  and  be  examined  there 
as  unloaded. 

State  Regulations. — There  are,  however,  two  great  needs  re- 
garding meat  inspection  that  are  the  immediate  concern  of  every 
individual.  The  State  regulations  regarding  meat  are  most  un- 
equal. Some  States  have  none  at  all.  As  stated  elsewhere,  this 
means  that  any  diseased  animal  may  be  killed  for  food.  It  also 
means  that  such  States  are  eating  meat  the  Federal  Government 
will  not  let  them  ship  to  other  States.  No  one  would  like  to  think 
he  was  eating  meat  not  fit  to  sell  to  other  people !  Every  State 
should  adopt  a  meat  inspection  law,  using  the  United  States  regula- 
tions as  a  model. 

Municipal  Regulations. — The  second  need  is  with  regard  to 
municipal  regulation.  Some  cities,  such  as  New  York  City,  are 
adequately  protected,  having  regulations  equal  to  the  federal  regu- 
lations. Every  city  and  every  other  small  community  should  de- 
mand that  all  animals  (except  possibly  fowls)  killed  for  food  should 
be  killed  in  a  municipal  slaughter  house.  An  inspector  should  be 
in  attendance  whenever  killing  is  done.  The  building  should  be 
rat-proof,  screened  against  flies,  and  have  all  the  sanitary  arrange- 
ments already  discussed.  The  disposal  of  refuse  should  be  properly 
attended  to — ^burial  or  burning  being  the  simplest  for  solids,  while 
blood  and  water  should  be  carried  off  in  a  closed  sewer  system  or 
disposed  of  in  a  sub-soil  drainage  system  (see  Sewage  Disposal 
Chapter  YII).  Such  fees  as  60  cents  for  a  beef,  30  cents  for  a  hog, 
have  been  found  feasible. 

Other  Methods  of  Killing. — It  is  expensive  to  slaughter  the 
animals  in   different  ways,   so   in   localities  with   a  large  Jewish 


FOOD  49 

population  the  large  supply  houses  commonly  kill  all  animals  by 
the  Jewish  method.  In  this  method  the  animals  are  not  stunned 
in  the  usual  way,  but  are  first  suspended  by  a  hind  leg,  and  then 
the  throat  is  cut  as  the  animal  hangs  head  downward.  The  aim  is 
to  secure  complete  drainage  of  blood  from  the  body.  This  method 
was  necessary  in  the  old  Mediterranean  home  land,  for  bacterial 
decomposition  would  progress  less  rapidly  in  the  drier  tissues ;  it  is 
not  necessary,  of  course,  with  the  present  cold  storage  facilities,  and 
a  general  adoption  of  the  method  in  which  the  animals  are  first 
stunned  would  appear  more  desirable.  There  seems  to  be  no  good 
reason  why  this  change  should  not  be  made,  as  the  Jewish  custom 
of  killing  chickens  does  not  include  bleeding ;  through  a  cut  in  the 
neck  the  windpipe  is  drawn  out,  causing  suffocation. 

So  many  of  the  ancient  Jewish  customs  have  been  found  to  have 
strong  bacteriological  support  that  it  is  hoped  that  these  particular 
methods  will  soon  be  changed. 

Other  Foods  to  be  Handled  Like  Meats. — The  regulations 
that  pertain  to  meats  are  generally  applicable  to  fish,  shellfish  and 
eggs.  Fish  has  been  the  cause  of  paratyphoid  infection  (p.  44) ;  in 
one  epidemic  at  least  the  direct  cause  was  the  infection  of  the  fish 
by  a  paratyphoid  carrier.  The  federal  pure  food  laws  here,  too,  pro- 
tect indirectly  in  interstate  trade,  imder  the  heading  of  food  unfit 
for  human  consumption.  Fish  has  been  already  mentioned  (pp.  45 
and  46)  ;  the  other  two  classes  are  discussed  briefly  below. 

Oysters. — Oysters  and  other  shellfish  are  sometimes  dangerous 
foods.  Typhoid  is  the  most  common  disease  traced  to  oysters; 
Jordan  thinks  the  danger  from  this  source  has  been  exaggerated. 
Since  bacteria  tend  to  die  off  in  winter  weather,  both  in  the  oyster 
and  in  the  surrounding  water,  we  have  the  popular  saying, 
"Eat  oysters  in  the  R-months  only."  Undesirable  bacteria 
may  enter  the  oysters  from  the  sewage-polluted  waters  in  which 
they  are  grown  or  stored.  When  oysters  are  placed  in  fresh 
water,  they  absorb  water  rapidly,  causing  the  more  delicate  tissues 
{e.g.,  gills)  to  look  swollen  or  fat.  Careless  dealers  sometimes 
fatten  oysters  in  any  convenient  tank  or  body  of  fresh  water,  with- 
out considering  the  conditions.  Bacteria,  such  as  typhoid  and 
B.  coli,  may  multiply  rapidly  in  warm  tanks,  or  sewage-polluted 
rivers.  One  oyster  collected  near  a  sewer-outlet  contained  17,000 
typhoid  bacteria.  If  undesirable  bacteria  are  present,  they  are 
4 


50  HOME  AND   COMMUNITY  HYGIENE 

found  in  the  liquid  and  in  tlie  delicate  gills  and  shell  membranes  as, 
well;  they  often  invade  the  more  solid  parts  also.  Pouring  oS  the 
liquid  simply  reduces  the  amount  of  danger;  it  does  not  remove  all 
danger.  Cooking  oysters  sometimes  destroys  or  lessens  these  dangers. 
In  epidemics  of  oyster  "ptomaine  poisoning"  those  cooking  their 
oysters  often  escape  poisoning  (see  p.  44). 

Chickens  and  eggs  have  also  their  special  problems.  They  may 
be  discussed  here,  as  cold  storage  is  the  only  widely  used  method 
of  preservation  for  either  (see  p.  54). 

Chickens  in  cold  storage  may  undergo  bax3terial  changes  chiefly 
because  of  the  invasion  of  bacteria  from  the  alimentary  canal.  This 
may  be  drawn  out  by  a  hook  made  of  wire  (wire-drawn  chickens), 
or  the  body  may  be  cut  open  in  the  usual  domestic  way  of  "  clean- 
ing fowls/'  and  the  intestines,  etc.,  removed.  Both  ways  break  the 
alimentary  canal  and  allow  the  escape  of  bacteria.  Most  chickens 
sold  from  cold  storage  are  undrawn,  the  dangers  of  bacterial  inva- 
sion being  less  through  the  uninjured  alimentary  canal  than  from 
its  broken  ends.  Farmers  often  keep  chickens  shut  up  a  day  or  two 
before  killing  them  to  allow  the  intestines  to  become  empty.  Feed- 
ing with  sand,  sawdust,  etc.,  is  recommended  as  having  even  a 
better  cleansing  action,  but  such  treatment  does  not  seem  to  be 
very  general. 

Eggs  are  far  from  bacteria  free.  Bacteria  enter  while  the  eggs 
are  still  in  the  oviduct,  and  the  forming  shell  encloses  them.  Eggs 
may  also  be  infected  through  the  shell  (manure  on  surface).  It  is 
thought  that  the  natural  glossy  film  on  the  surface  helps  prevent 
the  entrance  of  bacteria,  and  it  is  recommended  that  eggs  visually 
clean  should  not  be  washed.  Eggs  laid  in  the  cooler  spring  months 
have  a  lower  bacterial  count  than  July  or  August  eggs;  eggs  are 
usually  cheaper  also  in  the  spring  and  storage  firms  prefer  to  fill 
their  warehouses  during  April.  The  bacterial  content  is  lower,  and 
the  flavor,  therefore,  better. 

The  white  part  of  the  eggs  has  a  somewhat  germicidal  action  on 
bacteria ;  in  the  yolk  they  multiply  rapidly.  Xevertheless,  eggs  are 
much  less  liable  to  convey  disease  organisms  than  any  other  food 
obtained  from  animals ;  this  is  partly  due  to  the  fact  that  there  is 
apparently  no  hen  disease  to  which  man  is  susceptible. 


FOOD  51 


PROBLEMS 


1.  What  per  cent,  of  the  meat  sold  by  your  own  butcher  is  United 
States  inspected? 

2.  Does  your  State  issue  a  bulletin  regulating  the  cold  storage  of  eggs, 
meat  and  fish  ?  Are  they  enforced  in  your  community  ?  What  is  the  penalty 
for  non-observanee  of  these  regulations  ? 

3.  Chickens  and  eggs  do  not  come  under  Federal  inspection  regula- 
tions, except  as  canned  chicken,  dried  eggs,  or  egg  powders  come  under  the 
pure  food  laws  regarding  food  in  packages  (labels,  preservatives,  substi- 
tutions, putrescence  and  decomposition).  Does  your  State  protect  you  in 
any  way  from  decomposing  or  objectionable  conditions  in  such  foods? 

4.  Consult  the  meat  inspection  regulations  issued  by  the  United  States 
Government.  (Order  211,  Bureau  of  Animal  Industry).  How  many  of 
the  requirements  are  included  in  your  own  State  regulations?  WTiat  can 
be  done  to  improve  your  State  conditions?  Can  your  institution  select 
one  reform  and  carry  it  through  ? 

5.  Is  there  a  municipal  slaughter  house  in  your  town  or  community? 

6.  What  supervision  is  given  the  private  slaughter  houses  in  your  com- 
munity ?  What  are  the  standards  or  regulations  you  feel  to  be  satisfactory  ? 
Which  need  to  be  changed? 

FOOD    PRESERVATION 

The  hygienic  phases  of  the  food  problem  are  not  all  covered  by 
national  legislation :  the  Food  and  Drugs  rulings  and  the  Meat  In- 
spection Eegulations.  Milk  has  no  definite  national  legislation, 
I)ut  fortunately  the  standards  set  by  the  American  Association  of 
Medical  Commissions  has  had  some  effect  upon  the  various  State 
standards.  In  this  connection  it  must  be  remembered  that  the 
meat  regulations  are  enforced  only  for  interstate  trade,  and  that  in 
many  States  the  conditions  regarding  milk  are  no  worse  than  for 
meat  produced  within  that  State. 

Most  important  are  the  phases  having  to  do  with  the  preserva- 
tion of  foods,  including  cooking,  for  temporary  preservation  is 
often  one  of  the  aims  or  results  of  cooking. 

Aims. — The  recognized  methods  of  food  preservation  have  two 
main  aims:  (1)  to  free  food  of  infectious  organisms  {e.g.,  steriliz- 
ing tuberculous  veal  or  beef  to  make  it  safe  as  food)  ;  and  (2)  to 
conserve  food,  avoiding  spoilage  which  would  mean  a  loss  of  food 
value,  or  the  accumulation  of  undesirable  substances. 

Our  concentrated  urban  life,  the  seasonal  limitations,  and  the 
desire  for  the  best  of  the  foods  characteristic  of  other  localities  (e.g., 
tropical  fruits,  salt  water  foods)  make  the  methods  of  food  preserva- 
tion very  important  hygienic  considerations,  for  food  is  often  trans- 
ported thousands  of  miles  or  stored  for  months — sometimes  years. 


52  HOME  AND  COMMUNITY  HYGIENE 

Methods. — The  methods  of  preservation  concern  (1)  foods 
which  we  desire  to  keep  in  their  natural  condition,  such  as  fresh 
friiits,  vegetables,  and  eggs;  and  (2)  foods  often  considerably  modi- 
fied in  taste,  texture,  digestibility,  bulk,  and  appearance  by  cook- 
ing, the  addition  of  chemicals,  etc.  Our  interest  in  the  methods  is 
mainly  in  regard  to  these  latter  points  and  their  effect  upon  the 
health  of  the  consumer. 

Some  of  the  methods  are  very  ancient,  and  the  oldest  records 
show  that  people  dried,  salted,  smoked,  and  (in  favorable  localities) 
cooled  or  froze  their  foods.  We  will  discuss  first  the  methods  pro- 
ducing little  or  no  chemical  change  in  the  foods  {e.g.,  drying)  ;  and 
next  those  involving  chemical  changes  or  the  use  of  chemicals  {e.g., 
pickling). 

The  details  of  any  method  will  be  included  only  when  they  are 
of  general  interest  or  when  variations  of  the  method  affect  the  re- 
sults obtained  {e.g.,  the  effect  of  long  and  short  heating  periods 
upon  the  texture  of  canned  goods). 

Cold  as  a  Preservative. — Cold  has  attained  first  rank  as  a  pre- 
servative. Eosenau  cites  an  interesting  instance — a  mammoth  un- 
buried  by  an  avalanche  in  Siberia  which  was  so  well  preserved  that 
even  the  soft  fleshy  trunk  remained,  and  it  is  said  that  natives  as 
well  as  animals  ate  the  flesh  thus  released  from  its  icy  coverings. 
Parts  of  the  flesh  are  still  preserved  in  a  museum  in  Petrograd. 

Fortunately  it  is  not  necessary  to  have  extremely  low  tempera- 
tures to  secure  beneficial  refrigerating  conditions;  freezing  or  near 
freezing  are  adequate.  The  range  is  generally  from  5°  C.  (41°  F.) 
to -5°  C.  (23°  F.).  The  extremely  low  temperatures  are  relatively 
drier  temperatures,  and  so  really  less  effective  in  killing  bacteria.^'^ 

Beef  tapeworms  do  not  survive  21  days  at  ordinary  cold  storage 
temperatures.  Pork  tapeworms  are  much  more  resistant,  and  trich- 
inae are  killed  only  at  very  low  temperatures  (5°  F.  for  20  days). 
Spores  of  molds  or  bacteria  may  survive  freezing,  and  bacteria  may 
be  found  even  in  the  tissues  of  frozen  chickens. 

The  foods  commonly  preserved  by  freezing  are  meat,  poultry, 
and  fish.  Fish,  after  freezing,  are  sometimes  dipped  in  water  and 
refrozen.  The  outer  covering  of  fish  is,  of  course,  waterproof;  cut 
meats  would  not  be  improved  by  such  treatment. 

"  Dry  heat  and  dry  cold  are  both  less  efficient  in  killing  bacteria  than 
moist  heat  and  moist  cold;  the  former  penetrate  the  cells  less  rapidly. 


FOOD  53 

Cold  storage  temperatures  are  often  not  so  low  as  freezing. 
Fruits,  vegetables,  and  eggs  are  less  palatable  or  less  attractive  after 
freezing.  Temperatures  just  above  freezing  are  antiseptic  rather 
than  germicidal,  and  so  such  substances  as  eggs,  though  kept  in  cold 
storage,  may  have  a  high  bacterial  count.  Meat  and  fish,  hovs^ever, 
may  be  kept  for  a  long  time  without  noticeable  change.  Fish  kept 
two  years  at  cold  storage  temperatures  showed  no  change  that  could 
be  detected  by  any  chemical  tests.  The  flavor  of  eggs  is  not  im- 
proved by  cold  storage ;  hut  the  condition  is  certainly  better  than  if 
they  were  kept  for  equal  periods  at  ordinary  temperatures.  Fruits 
and  vegetables  do  not  deteriorate  during  cold  storage. 

Prejudices  against  cold  storage  are  hard  to  change.  People  have 
been  known  to  refuse  to  eat  cold  storage  fish  free  from  bacteria  and 
decomposition  changes,  substituting  instead  cold  storage  eggs  or 
Hamburger  steak,  the  bacterial  content  of  each  often  reaching  a 
million  per  cubic  centimetre  (G). 

In  reality  cold  storage"  is  the  best  method  of  preserving  food 
materials;  it  leaves  the  original  substance  unchanged,  adding  and 
subtracting  nothing;  the  original  flavor  is  retained,  the  texture, 
digestibility,  and  nutritive  qualities  are  not  affected. 

Why,  then,  this  prejudice  against  cold  storage  foods?  It  is  be- 
cause materials  taken  from  cold  storage  chill  the  surrounding  air 
sufficiently  to  cause  its  water  vapor  to  condense  on  their  surfaces; 
this  water  mixes  with  the  juices  on  the  cut  or  broken  surfaces, 
making  favorable  food  material  for  bacteria  which  have  survived 
cold  storage,  or  which  may  chance  to  settle  there  (air  currents  in 
dusty  stores  or  streets,  or  fingers  of  prospective  customers) .  Decay 
progresses  rapidly  under  such  conditions.  In  some  cases  this  con- 
densation of  water  may  be  prevented  by  wrapping  the  fruits  in  ab- 
sorbent paper  (oranges)  or  using  absorbent  material  as  packing 
(coarse  sawdust  for  grapes).  Meat  is  sometimes  dried  a  little  be- 
fore cold  storage  to  make  a  drier  covering,  less  easily  penetrated  by 
bacteria." 

^*  House  refrigerators  rarely  even  approach  cold  storage  temperatures. 
Most  house  ice  boxes  do  not  fall  below  10°  C.  (50°  F.),  and  15°  (59°  F.) 
is  not  unusual  in  parts  of  house  refrigerators,  especially  when  the  door 
does  not  fit  tightly  or  is  carelessly  left  ajar. 

'* Country  people  often  keep  the  cut  ends  of  ham  from  molding  by 
rubbing  a  little  fat  over  the  cut  surface.  The  fatty  film  is  less  favorable 
for  mold  growth  than  the  moist  lean  meat  surface. 


54  HOME  AND  COMMUNITY  HYGIENE 

The  prejudice  against  cold  storage  meats  and  fish  has  led  re- 
tailers to  thaw  such  materials  before  offering  them  for  sale.  Unsold 
material  is  often  re-cooled.  The  retailer's  ice  boxes  rarely  reach 
killing  temperatures,  and  meats  alternately  cooled  and  warmed  are 
subject  to  great  bacterial  change.  The  practice  of  thawing  meat 
and  fish  in  water  is  forbidden  in  all  alert  communities;  one  needs 
but  to  think  for  a  minute  of  the  possibilities  of  bacterial  contamina- 
tion of  chicken  and  other  meats  one  might  expect  if  they  were 
thawed  in  barrels  or  tubs  of  water  in  such  secret  places  as  cellars 
and  back  sheds.  It  is  easy  to  see  one  should  insist  on  buying  cold 
storage  meats  in  their  original  chilled  condition,  and  keep  them 
cool  until  time  for  cooking. 

Another  strong  argument  for  cold  storage  meat  is  that  this 
process  is  usually  applied  to  meat  coming  from  a  distance,  that  is, 
outside  the  State;  such  meat,  therefore,  usually  must  pass  the 
federal  inspection  necessary  for  interstate  commerce.  Such  meat 
bears  the  government  stamp  on  all  large  pieces  of  meat,  which 
guarantees  to  the  consumer  that  it  came  from  a  healthy  animal, 
was  killed  under  sanitary  conditions,  and  found  free  of  com- 
municable diseases  (see  meat  inspection,  p.  45). 

Cold  storage — the  simplest  of  all  methods  of  food  preservation 
— has  grown  rapidly  in  public  favor.  Its  general  applicability 
to  all  foods  has  led  to  manipulation  of  the  markets  to  secure  high 
prices.  To  meet  this  some  States  now  limit  the  length  of  time  cer- 
tain foods  {e.g.,  ten  months  for  eggs)  may  be  retained  in  cold 
storage.  This  is  designed  to  prevent  a  storage  through  consecutive 
producing  seasons  and  "  cornering  the  markets." 

Preservation  by  Heat. — Canning  or  preservation  by  heat  was 
used  universally  in  this  country  about  forty  years  before  refrigera- 
tion. The  story  goes  that  ISTapoleon,  feeling  the  need  of  better  food 
supplies  for  the  army,  offered  a  prize  of  12,000  francs  for  a  new 
method  of  keeping  food  which  was  not  based  on  the  use  of  any  pre- 
servatives then  in  use.  The  prize  was  won  in  1804"  by  Appert, 
who,  however,  used  no  chemicals  at  all.  His  perfected  method  con- 
sisted of  heating  the  cans  in  boiling  water.  He  wrote  a  description 
of  his  methods  in  1811,  calling  it  a  "  Treatise  of  the  Art  of  Preserv- 

^A  Swede  in  1786  canned  vinegar;  the  keeping  power  of  the  canned 
vinegar  -was  probably  due  to  its  acetic  acid  rather  than  the  perfection  of 
his  canning  process. 


FOOD  55 

ing  Vegetable  and  Animal  Substances."  A  patent  was  soon  taken 
out  in  England  for  this  secret  "  divulged  by  a  foreigner  residing 
abroad'';  and  soon  (1819-20)  the  process  was  in  full  operation  in 
the  United  States,  for  fruits,  fish,  oysters,  etc.  Most  of  the  sub- 
stances seem  to  have  been  acid  fruits,  rather  "  easy  to  keep,''  but  corn 
was  successfully  canned  in  Maine  in  1837.  Canning  was  done  both  in 
tin  and  glass  as  early  as  1820.  A  great  impetus  was  given  to  can- 
ning by  the  army  needs  in  the  Civil  War,  and  it  has  become  firmly 
established  as  a  desirable  method  of  food  preservation. 

The  addition  of  sugar  (jams,  jellies,  and  preserves)  increases 
the  keeping  power  of  such  canned  goods.  Most  bacteria  find  it  dif- 
ficult to  grow  in  such  concentrated  sugar  solutions,  as  water  is 
withdrawn  from  the  bacteria  themselves  to  satisfy  the  affinity  of 
sugar  for  water. 

Eosenau  says  that  heat  and  cold  are  the  only  proper  preserva- 
tives. Heat  shares  with  cold  certain  advantages  over  other  methods. 
It  does  change  the  flavor  of  fruits  and  milk  somewhat,  of  course; 
but  since  vegetables,  meats,  and  fish  are  always  used  cooked,  that  is 
of  little  importance  in  most  canned  goods.  It  has  one  decided  ad- 
vantage over  r'ef rigeration :  the  bacteria  present  are  usually  killed  " 
and  decomposition  products  are  often  rendered  harmless.  Other 
advantages  claimed  for  cooking  and,  therefore,  canning  are  the  de- 
velopment of  new  or  improved  flavors  and  increased  digestibility 
(e.g. J  in  starchy  vegetables). 

Methods  of  Canning. — ^There  are  two  main  types  of  canning. 
The  first  is  practised  only  in  the  home,  and  consists  of  boiling  the 
fruits  or  vegetables  until  the  bacteria  have  been  killed  (usually  10 
to  15  minutes),  and  putting  the  contents  aseptically  into  a  can 
which  has  been  more  or  less  completely  sterilized  with  boiling  water. 
If  filled  to  the  top,  and  so  enclosing  little  germ-laden  air,  the  can 
usually  "  keeps,"  either  (1)  because  no  live  bacteria  were  shut  in  the 
can  or  (2)  because  they  failed  to  develop,  lacking  sufficient  oxygen, 
or  were  killed  by  the  heat  left  in  the  hot  material. 

In  the  second  type  the  uncooked  materials  to  be  canned  are  put 
into  a  clean  can,  and  heated  in  one  of  several  ways,  as  described  in 
the  next  paragraphs.   This  can  is  closed  except  for  a  small  vent  hole 

^1  Canned  goods  sometimes  spoil,  (1)  because  bacteria  (chiefly  spores) 
survive  the  cooking  or  canning  process,  or  (2)  because  the  can  is  not 
perfectly  sealed  and  organisms  gam  entrance  later. 


56  HOME  AND  COMMUNITY  HYGIENE 

(or  loosened  cap)  for  the  escape  of  the  enclosed  air  as  it  expands  by 
heat.  This  vent  is  closed  promptly  before  the  can  cools ;  as  the  en- 
closed air  cools  and  contracts,  a  partial  vacuum  is  formed.  This 
eslplains  why  glass  can  tops  resist  opening  and  why  tin  cans  look 
slightly  drawn  in  at  the  ends.  Sometimes  the  hot  air  is  drawn  out 
of  the  tin  cans,  making  the  space  above  the  contents  more  nearly  a 
vacuum.  Most  organisms  need  oxygen  for  their  development,  and 
the  limited  amount  of  air  left  in  the  can  has  a  deterrent  effect  on 
such  bacteria  which  survive  the  heating  process.  (Tin  cans  are 
often  heated  after  sealing  to  make  sure  they  are  perfectly  sealed.) 

The  second  type,  where  the  uncooked  materials  are  put  into 
cans  before  any  heat  is  applied,  is  used  commercially  as  well  as  in 
the  home.  This  type  includes  (a)  boiling  temperatures  and  (6) 
still  higher  temperatures,  where  the  surrounding  water  or  steam  is 
heated  under  pressure. 

We  will  discuss  first  the  cold  pack  method  and  the  discontinuous 
method,  which  use  boiling  temperatures  only ;  later  we  will  discuss 
the  steam  pressure  methods. 

The  Cold  Pack  Method. — In  the  cold  pack  method  the  cans  of 
uncooked  vegetables,  etc.,  are  surrounded  by  cold  water  in  a  wash 
boiler  or  a  similar  container.  The  water  is  heated  and  held  at  the 
boiling  point  for  a  definite  period  of  time,  varying  from  30  or  40 
minutes  for  some  vegetables  to  2  or  3  hours  for  corn.  The  time 
depends  partly  upon  the  solidity  with  which  the  material  packs 
or  the  rate  of  heat  penetration,  and  partly  upon  the  resistance 
of  the  organisms  usually  found  on  the  vegetables,  (Eesistant 
spore  bearers  are  thought  responsible  for  the  difficulty  experienced 
in  canning  corn.) 

The  Discontinuous  Method. — Discontinuous  sterilization  is 
more  often  practised  in  the  home  than  in  factories.  The  cans  are 
heated  in  the  water  bath  as  in  the  cold  pack  method,  for  a  definite 
period  of  time  designed  to  kill  all  bacteria  not  in  the  resistant 
spore  stage.  After  standing  at  room  temperature  the  process  is  re- 
peated the  next  daj^,  and  usually  a  third  time  on  the  third  day  or  at 
least  within  a  week,  thus  making  quite  sure  of  catching  the  bacteria 
in  a  growing  or  vegetative  stage.  This  process  is  rarely  used  com- 
mercially, as  it  involves  too  much  man  labor,  and  such  prolongation 
of  the  heating  period  may  make  the  materials  too  soft  and  mushy. 

Pressure  Methods. — In  this  method  we  use  steam  under  pres- 


FOOD 


57 


Bure,  as  in  the  now  popular  pressure  cookers  (Fig.  18).  In  the 
bottom  of  these  little  steam  boilers  is  a  supply  of  water  and  the  jars 
rest  on  a  framework  in  this  water  chamber.  The  steam  is  not 
allowed  to  escape  and  the  pressure  and  temperature  alike  rise  until 
we  have  a  pressure  two  or  more  times  ordinary  atmospheric  pres- 
sure, and  a  temperature  far  above  boiling  (e.g.,  125°  C.  or  257°  F.). 
Commercial  canning  is  almost  entirely  of  this  type,  but  the  steam 
chambers  holding  the  cans  are,  of  course,  much  larger  than  in  the 
pressure  cooker,  and  connected  by  pipes  with  the  boiler  containing 
the  water  which  forms  the  steam  (Fig.  19). 


FiG.18. — Pressure  cookers,  lid  off  in  one  on  right.  When  in  use  clamps  hold  the  lid 
shut  and  so  increase  the  pressure  and  temperature.  The  simplest  types  of  autoclaves  for 
bacteriological  work,  sterilizing  glassware,  etc.,  resemble  these  pressure  cookers. 

Containers  for  Canned  Goods. — Glass  and  tin  have  their  re- 
spective advantages  and  disadvantages.  Glass  is  heavier,  less 
adapted  to  shipping  and  to  handling  by  automatic  machinery;  the 
bleaching  efEect  of  light  is  not  prevented,  and  poor  qualities  of  glass 
may  liberate  objectionable  substances  (e.g.,  fluorides  (G),  lead). 
Tin  cans  are  better  adapted  to  commercial  handling.  If  the  tinned 
surfaces  are  broken,  metallic  salts  may  be  formed.  Acid  fruits  may 
attack  the  tin  itself.  This  is  prevented  by  a  special  coating  or 
lacquer — ^more  or  less  a  trade  secret — which  is  not  .necessary  in  peas 


58 


HOME  AND  COMMUNITY  HYGIENE 


and  such  vegetables.  Practically  all  authorities  agree  that  harmful 
tin  salts  are  rarely  found  in  amounts  worth  considering.  Harring- 
ton doubts  if  they  even  equal  the  tin  worn  or  scraped  ofE  of  sauce- 
pahs  and  kettles.  The  popular  prejudice  against  tinned  vegetables 
has  little  but  blind  prejudice  to  support  it,  and  if  it  is  a  question  of 
canned  vegetables  or  no  vegetables,  no  one  should  hesitate  a  second. 
Canned  meat  lost  in  a  shipwreck  and  found  forty-four  years  after- 
ward was  in  good  condition,  and  eaten  without  injury. 


Fig.  19. — In  commercial  canning  the  cans  are  put  into  frames  or  baskets  and  heated  as 
in  the  pressure  cooker.  Instead  of  forming  steam  in  each  chamber,  steam  is  usually  piped 
in  from  a  boiler  in  the  engine  room. 

Preservation  by  Drying. — Drying,  the  third  method  of  preser- 
vation involving  little  or  no  chemical  change  in  the  substances,  may 
be  accomplished  at  ordinary  temperatures,  or  at  the  higher  tem- 
peratures used  in  canning. 

Substances  which  change  in  color  as  they  dry  are  nowadays  dried 
quickly,  to  lessen  these  oxidation  changes  {e.g.,  browning  of  cut  sur- 
faces of  apples).  Though  not  completely  dried  (25  to  30  per  cent, 
water  is  left  in  dried  fruits)  bacteria  do  not  grow  readily  in  or  on 


FOOD  59 

such  surfaces.  Sometimes  substances  such  as  meats  are  subjected 
for  a  short  time  to  a  very  drying  atmosphere  to  make  a  very  dry 
surface  which  does  not  encourage  bacterial  development,  after  which 
they  are  put  into  cold  storage.  Milk,  eggs,  vegetables  and  fruits 
can  be  dried  very  readily  and  with  but  little  loss  in  nutritive  value. 
Eggs,  like  milk,  may  be  dried  by  spreading  the  egg  mixture  on  hot 
trays,  or  on  a  revolving  metal  belt  from  which  small  brushes  collect 
the  dried  powder;  or  the  mixture  may  be  sprayed  into  a  heated 
chamber  in  such  a  fine  spray  that  it  dries  before  it  falls  to  the 
bottom. 

Chemicals  as  Additions  to  Drying  Processes. — Apples  and 
substances  which  naturally  undergo  oxidative  color  changes  may  be 
bleached  by  such  substances  as  sulphur  gas ;  one-half  the  apples  on 
the  market  are  said  to  be  sulphur  treated.  Molds  and  bacteria  do 
not  multiply  so  rapidly  on  treated  apples,  the  sulphur  serving  as  a 
preservative.  Metallic  substances  from  the  drying  trays  have  been 
reported  in  dried  apples. 

In  drying  meats,  smoking  is  sometimes  part  of  the  process ;  less 
often  salting  is  combined  with  the  drying  process.  The  meat  may 
be  hung  over  smouldering  wood  which  is  giving  off  creosote,  acetic 
acid  or  formaldehyde.^^  The  interior  of  the  mass,  as  in  meat  ground 
up  for  sausage,  may  contain  bacteria,  and  meat  poisoning  {e.g.^  by 
B.  hotulinus,  which  develops  toxins),  may  result.  When  whole  pieces 
of  fresh  meat  are  dried,  this  is  less  likely.  Instead  of  hanging  meats 
over  wood  fires,  much  the  same  efilect  can  be  secured  by  treating 
the  meat  with  a  preparation  called  "  smoke,"  containing  creo- 
sote, etc. 

Preservation  by  Chemical  Agents  or  Changes. — Foods  are 
also  preserved  by  methods  which  depend  upon  the  addition  of 
chemicals,  or  cause  a  decided  chemical  change  in  the  substances  to 
be  preserved:  fermentation,  pickling,  and  salting. 

Fermentation,  Salting,  and  Pickling, — Fermentation,  salting, 
and  pickling  as  preservative  processes  may  be  treated  together. 
Foods  are  sometimes  packed  in  dry  salt  (2  to  3  pounds  salt  to  100 
pounds  cabbage  in  making  sour-krout),  and  sometimes  in  salt  solu- 
tion (5  pounds  of  salt  to  every  12  gallons  of  water  in  making 
dill  pickles).     In  the  cases  just  used  as  illustrations  the  plant 

22 Beech,  hickory  and  oak  are  favorite  woods;  some  of  the  other  woods 
give  off  turpentine,  etc.,  and  are,  therefore,  undesirable. 


60  HOME  AND  COMMUNITY  HYGIENE 

juices  are  drawn  out  and  are  fermented  by  the  lactic  acid  bacteria 
common  in  the  air  and  on  plant  surfaces.  In  timC;,  the  lactic  acid 
accumulated  kills  the  bacteria  and  prevents  further  changes  in  the 
material,  unless  objectionable  resistant  molds  develop.  These  may 
usually  be  prevented  by  a  covering  of  oil  or  paraffin  after  the  fer- 
mentation is  completed. 

Many  vegetables  may  be  satisfactorily  fermented  in  brine:  cu- 
cumbers, string  beans,  beets,  corn,  green  peas,  and  green  tomatoes. 
They  have,  of  course,  a  slightly  acid  taste,  which  is  most  marked  in 
the  corn.  If  still  stronger  salt  solutions  are  used,  even  the  lactic 
acid  bacteria  cannot  develop;  in  this  ease  we  have  salting  without 
fermentation.  This  method  may  be  used  for  greens  generally 
(spinach,  dandelior  tops,  etc.)  and  for  kale,  cabbage,  string  beans, 
peas,  and  corn.  Before  using  these  are  well  washed  and  cooked 
as  usual  (sometimes  in  renewed  waters  to  remove  more  salt). 

If  vinegar  is  used  its  acetic  acid  acts  like  the  lactic  acid  and 
"  keeps  "  the  materials.  Sugars  and  spices  may  be  added  to  vinegar 
to  increase  its  preserving  power.  Materials  may  be  packed  in  brine 
first  and  then  in  vinegar.  In  meats,  such  as  ham,  salting  is  followed 
by  smoking  and  drying.  The  "  cold  water  canning  "  of  raw  rhubarb 
"  keeps  "  because  of  the  large  amount  of  acetic  acid  in  rhubarb. 

The  disadvantages  of  all  these  methods  are  chiefly  that  they 
change  the  flavor  and  make  the  food  less  nutritious:  the  fibers  are 
toughened  and  some  of  the  proteins  are  made  insoluble;  some  of 
the  soluble  proteins  are  drawn  out  by  the  salt  and  so  lost.  The 
main  advantages  are  that  a  great  deal  of  material  can  be  preserved 
with  a  minimum  of  time  and  labor,  and  that  inexpensive  containers 
can  be  used  (e.g.^  old  kegs,  butter  tubs,  and  jars  lacking  covers). 

Addition  of  Chemicals. — The  addition  of  chemical  preserva- 
tives in  all  articles  of  food  entering  into  interstate  commerce  (or 
so  widely  advertised  as  to  render  interstate  sale  probable)  is  now 
controlled  by  the  federal  government  under  the  pure  food  and 
drugs  laws.  Some  States  and  cities  reinforce  this  by  local  protec- 
tive legislation. 

Our  present  methods  of  food  preservation  do  not  necessitate  the 
addition  of  chemical  preservatives  in  any  goods  sold  in  glass  or  tin 
containers.  Care  in  drying  and  final  handling  makes  it  possible  to 
handle  many  substances  in  oiled  or  paraffined  paper,  or  tin  foil  for 
short  periods  of  time,  while  substances  containing  little  water  may 


FOOD  61 

be  kept  indefinitely  in  paper  {e.g.,  coffee),  if  kept  dry.  It  is  only 
Avhere  materials  are  used  slowly  (catsup  on  the  table,  open  kegs  of 
apple-butter  in  retail  stores)  that  any  preservative  could  be  neces- 
sary, and  the  federal  government  rightly  limits  such  processes  as 
the  chemical  bleaching  of  flour  and  dried  fruits,  or  the  addition  of 
chemicals  to  sauces  and  catsups,  classifying  such  additions  as  adul- 
teration. There  is  no  argument  for  the  addition  of  chemicals  to 
hide  the  poor  quality  of  the  substance:  to  bleach  darker  meats  to 
"  chicken,^^  to  harden  the  soft,  decaying  fibres  of  vegetables,  or  bring 
back  the  color  of  old  meats  or  spoiling  vegetables. 

Certain  chemicals  classed  as  natural  preservatives  are  used  in 
every  home  as  antiseptics  rather  than  germicidal  agents — spices  in 
fruit  cake  or  sausage.  Even  these  must  not  be  used  indiscrimi- 
nately, as  some  are  irritating  to  mucous  membranes  and  therefore 
harmful.  The  most  valuable  ones  are  cinnamon,  mustard,  and 
cloves,  though  the  last  gives  little  aid  in  amounts  pleasant  to  the 
taste.    Vinegar,  salt,  and  sugar  are  other  home  preservatives. 

Certain  commercial  processes,  such  as  putting  a  film  of  gum 
benzoin  on  chocolate  candy,  is  even  approved.  Shellac  as  coating  for 
candy  may  be  injurious,  as  it  sometimes  contains  arsenic.  Slowly 
consumed  catsups  and  sauces  may  be  allowed  a  little  preservative 
(benzoate  of  soda),  as  the  amount  of  catsup  or  sauce  eaten  is  usually 
too  small  to  make  the  preservative  a  consideration. 

PROBLEMS 

1.  Farmer'a  Bulletin  903  indicates,  that  but  one  State  has  enacted  laws 
regulating  the  quality  of  evaporated  or  dried  fruits.     Is  that  your  State? 

2.  What  foods  are  kept  in  cold  storage  in  your  State?  What  regula- 
tions govern  the  temperature  used,  the  time  limit? 

3.  Delaware,  Indiana,  New  York  and  New  Jersey  require  that  the  date 
of  entry  be  stamped  on  cold  storage  eggs;  Indiana  and  New  York  demand 
also  the  date  of  withdrawal;  New  York  and  New  Jersey  limit  egg  storage  to 
ten  months.  Are  these  rulings  justifiable?  How  does  your  State  differ  in 
these  respects? 

4.  Criticise  a  recent  New  York  State  requirement  that  retail  stores 
offering  cold  storage  foods  for  sale  display  conspicuous  placards  to  that 
effect. 

5.  Find  for  each  method  of  food  preservation  a  substance  or  condition 
presenting  peculiar  difficulties;  e.g.,  recently  the  salt  codfish  industry  has 
suffered  great  losses  from  red-pigmented  organisms  which  multiply  rapidly 
in  saturated  salt  solutions. 

See  Reference  List  at  end  of  Appendix. 


CHAPTEE  IV 

MILK 

Milk  has  a  double  claim  to  our  attention.  It  is  more  impor- 
tant and  more  valuable  than  any  other  single  food.  It  is  also  the 
source  of  more  disease  than  all  other  foods,  water  included.  There- 
fore, whether  our  primary  interest  is  infant  welfare,  the  scientific 
feeding  of  the  community,  or  decreasing  the  human  death  rate, 
milk  is  of  first  importance. 

Nutrients  in  Milk. — As  an  article  of  food  its  value  cannot  be 
overestimated.  It  is  rich  in  the  principal  food  elements,  as  shown 
by  the  following  table : 

Water    87.1  per  cent. 

Fat 3.9  per  cent. 

Protein   ( casein,  albumin) 3.2  per  cent. 

Milk  sugar  5.1  per  cent. 

Minerals  (salts)    0.7  per  cent. 

100.0  per  cent. 

Yet  how  valuable  a  food  milk  is  few  people  realize.  The  tables 
of  food  equivalents  which  show  one  quart  of  milk  as  equal  to  eight 
eggs  seem  questionable  to  most  of  us.  Even  if  we  say  we  believe  it, 
how  many  of  us  would  substitute  an  eighth  of  a  quart  of  milk  for 
our  morning  egg  and  feel  equally  well  fed  ?  The  food  value  of  milk 
is  further  realized  on  studying  this  next  table  showing  the  sub- 
stances composing  the  13  per  cent,  of  solids  found  in  milk. 

Butter  fat  (nine  kinds  of  fats:  olein,  butyrin,  etc.)  3.6  p«r  cent. 

Proteins    (five  kinds:    casein,  albumin,  etc.) 3.8  per  cent. 

Sugar    4.5.  per  cent. 

Minerals  (eight  elements  usually  in  compounds 
— oxides)  :     potassium,     phosphorus,     calcium, 

chlorin,  sodium,  sulphur,  magnesium  and  iron.  0.7  per  cent. 

Total  solids   12.6  per  cent. 

Standards  for   Milk   Nutrients. — The   legal   standards  vary- 
greatly  throughout  the  United  States;  for  example,  the  require- 
ment for  total  solids  varies  from  8.0  per  cent,  to  9.75  per  cent.    The 
U.  S.  Department  of  Agriculture  standards  are  briefly  as  follows : 
62 


MILK 


63 


Whole  mUk 

Skim  milk 

Cream 

Condensed 

milk 
(sweetened) 

Evaporated 

milk 
(unsweetened) 

Fats 

per  cent. 

3.25 
8.50 

per  cent. 

per  cent. 

18 

per  cent. 

7.7 

per  cent. 
7.8 

Solids  not  fat. . 

Total  solids 

9.25 

28.0 

25.5 

Since  fats  are  the  substances  most  often  withdrawn  from  milk 
by  unscrupulous  dealers,  and  since  fats  are  all-important  in  butter 
making,  these  are  emphasized  in  all  tests  of  milk.  Because  of  this, 
many  fail  to  appreciate  the  protein  value  of  milk.  It  is,  even  to-day, 
probably  the  cheapest  form  of  protein  except  cheese,  the  very  cheap- 
est cuts  of  meat,  and  salt  fish. 

Different  breeds  of  cattle  and  different  individuals  of  the  same 
breed  give  milk  varying  considerably  in  the  percentage  of  fats  and 
total  solids.  An  individual  cow,  too,  shows  considerable  variation, 
depending  upon  general  health,  exercise,  type  of  food,  length  of 
time  since  calving,  and  the  intervals  between  milking.  To  illus- 
trate, in  summer  the  shorter  interval  between  the  evening  and  the 
morning  milking  may  give  in  the  morning  a  smaller  amount  of 
milk  which  may  be  higher  in  fat  content.  The  type  of  milker 
(treatment  or  reaction  of  the  cow)  also  affects  the  fat  content.  The 
last  part  of  any  milking  yields  milk  richer  in  fats ;  incomplete  milk- 
ing due  to  ignorance  or  undue  haste  on  the  part  of  the  milker  yields 
milk  low  in  fat  value. 

The  above  variations  have  led  many  to  prefer  minimum  require- 
ments for  the  fats  and  total  solids  instead  of  an  average  which 
honest  milk  might  occasionally  fail  to  reach.  This  may  lead  to  a 
slightly  lower  milk  c[uality,  but  it  assures  the  consumer  of  a  definite 
value  for  his  money,  and  it  avoids  completely  the  unpleasant  and 
often  difficult  task  of  proving  that  low-grade  milk  has  been  adul- 
terated by  the  producer  or  dealer. 

Another  reason  why  milk  is  such  a  valuable  food  is  that  it  is 
readily  utilized  in  the  body.  Sherman  states  that  97  to  98  per 
cent,  of  the  milk  protein  is  digested  and  absorbed;  milk  fats  are 
already  emulsified  and  more  readily  available  than  any  common 
food  fats,  except  egg  fats.  The  popularity  of  milk  as  a  diet  for 
invalids  as  well  as  for  children  is  therefore  easily  understood. 


64  HOME  AND  COMMUNITY  HYGIENE 

Colostrum. — Just  before  and  after  the  birth  of  the  calf^  the 
milk  (colostrum)  differs  materially  in  appearance  and  quality.  It 
contains  dextrose  rather  than  lactose;  fats  more  like  the  fat  of  the 
tissues  than  of  milk.  It  is  higher  in  proteins  and  often  coagulates 
on  boiling,  even  though  freshly  drawn.  Its  specific  gravity  is 
greater,  and  it  may  be  less  attractive  in  appearance,  often  yellowish 
(excess  fat)  to  brownish  (red  blood-cells)  in  color.  It  is  some- 
times slimy,  sticky  or  stringy ;  and  the  odor  is  "  peculiar  "  or  un- 
pleasant, and  the  taste,  salty.  While  evidently  suited  to  the  new- 
born calf,  it  is,  to  say  the  least,  not  attractive  to  human  beings. 
Though  not  injurious  to  man,  it  has  a  decided  laxative  effect,  and 
most  health  authorities  forbid  its  sale  (for  about  15  days  before  and 
7  to  12  days  after  the  birth  of  the  calf). 

Bacterial  Changes  in  Milk. — Its  value  as  a  food  for  human 
beings  makes  it  also  a  valuable  food  for  other  kinds  of  cells — bac- 
terial cells,  for  example;  both  molds  and  bacteria  multiply  rapidly 
in  milk.  These  organisms  break  up  the  foods,  forming  other  sub- 
stances which  we  do  not  ordinarily  want  in  milk:  mainly  lactic 
acid  from  the  sugar,  and  ill-tasting  substances  from  the  milk  pro- 
teins. Such  bacterial  accumulations  may  cause  unpleasant  tastes  or 
odors  ^  {e.g.,  fishy  odor,  bitter  or  sour  taste)  ;  they  may  change  the 
texture  of  the  milk,  making  it  "  crack  "  or  "  separate  "  as  in  ordi- 
nary sour  milk,  or  thicken  into  a  semi-solid  or  less  often  a  slimy 
mass.  Such  changes  make  milk  less  appetizing  and  less  desirable 
a.-  food,  less  useful  in  cooking,  and  often  wholly  unusable  for  do- 
mestic purposes. 

An  analysis  of  about  thirty  samples  of  milk  averaging  3  to 
30  millions  of  bacteria  per  c.c.  (G),  showed  five  types  of  bacteria 
causing  such  changes:  9-11  per  cent,  acid-forming  (not  coagulat- 

*  Milk  absorbs  odors  very  readily.  These,  while  not  dangerous,  may 
affect  the  palatability  of  milk,  and  should  be  guarded  against.  Objection- 
able odors  are  sometimes  absorbed  from  manure,  ensilage,  turnips,  or 
even  potatoes,  if  the  milk  is  left  too  long  near  such;  substances.  In  the 
house  refrigerator  similar  odor  changes  may  occur.  Sometimes  the  "fishy" 
taste  may  be  due  to  rusty  vessels  or  to  remnants  of  soap  powder.  Occa- 
sionally the  odor  is  due  to  the  cow's  food;  garlic  contains  a  volatile  oil 
which  may  be  eliminated  through  the  udder. 


MILK 


65 


ing) ;  12-36  per  cent,  acid-forming  and  coagulating;  6-19  per 
cent,  alkali-forming;  14-17  per  cent,  peptonizing;  39-43  per  cent, 
inert,  producing  no  decided  change  in  milk. 

Disease  Organisms  in  Milk. — A  second  reason  why  milk  is 
dangerous  is  that  it  often  carries  disease-producing  bacteria.  Milk 
is  credited  with  a  "  greater  potentiality  to  disease  "  than  any  other 
food.  Many  of  the  pathogenic  bacteria  are  inert,  e.g.,  tuberculosis, 
typhoid,  paratyphoid,  and  diphtheria,  and  their  presence  is  usually 
wholly  unsuspected.     Hidden   in  its  milky  whiteness  pathogenic 


Diseases  Definitely  Teaced  to  Milk 


Disease 

Treatment  of  milk 

Effect  on  man 

Bovine  diseases: 
Streptococcus  infection 
of  udder 

Pasteurize;  discard  if  ab- 
normal in  appearance 
Best  to  discard 

Do  not  use 

Pasteurize;  milk  may  be 

safe,  if  no  exterior  pus 

enters 
Do  not  use;  spores  not 

killed  by  pasteurizing 

Pasteurize ;  discard  in 
case  of  open  lesions  or 
udder  infections 

Do  not  use 

Pasteurize  or  discard 
Pasteurize 

Pasteurize 
Pasteurize 
Pasteurize 
Pasteurize 
Pasteurize 
Pasteurize 
Pasteurize 

Pasteurize 
Pasteurize 

Diarrhoea;    septic  sore 

throat 
Fever,     diarrhoea,   skin 

eruptions,      especially 

in  children 
Smallpox  in  man 
Not  transmitted  to  man 

Foot-and-mouth  disease 
Cowpox 

False  cowpox 

Anthrax 

Anthrax  in  man 

Actinomycosis    (lumpy 
jaw,  etc.) 

No  record  of  transmis- 

Trembles (milk  sickness) 

Infectious  abortion 

Tuberculosis 

sion  to  man 

Vomiting,        paralysis, 
death 

May    be    injurious    to 

man 
Children  especially  sus- 
ceptible 

Human  diseases: 
Typhoid 

Paratyphoid 

Septic  sore  throat 

Tuberculosis 

Diphtheria 

Scarlet  fever 

Diarrhoea  and  dysentery 
(Probably  carried  by 
milk) 

Whooping-cough 

Measles . . 

66  HOME  AND  COMMUNITY  HYGIENE 

bacteria  find  their  wa}^  into  the  human  body,  lodging  in  the  throat 
(diphtheria),  causing  digestive  disturbances  in  the  alimentary 
canal  (dysentery)  or  passing  via  the  intestine  to  other  parts  of  the 
body  (tuberculosis  to  the  lungs  or  lymph-glands,  or  typhoid  into 
the  blood).  These  pathogenic  bacteria  may  be  merely  carried  by 
the  milk  {e.g.,  sore  throat  organisms  left  in  the  milk  by  the  care- 
less handling  of  a  dairyman  or  waitress).  Or  if  the  temperature  of 
the  milk  is  favorable,  such  undesirable  bacteria  may  actually  grow 
and  multiply  in  the  milk,  thereby  increasing  the  probabilities  of 
disease  transfer. 

That  diseases  are  carried  by  milk  has  been  proven  beyond  a 
doubt.  Peculiar  and  easily  recognized  forms  have  been  demon- 
strated by  the  microscope,  e.g.,  tuberculosis.  Single  cases  and  epi- 
demics have  been  traced  to  milk  supplies  in  ways  that  preclude  their 
explanation  as  mere  coincidences. 

Not  only  are  there  a  large  number  of  diseases  transmitted 
through  milk,  but  a  single  supply  may  be  responsible  for  many 
cases  of  disease.  One  diseased  cow  or  one  disease-bearing  worker 
in  a  dairy  may  infect  a  large  number  of  people — through  a  single 
lot  of  milk,  or  through  successive  lots  of  milk.  Dozens  or  even 
hundreds  of  cases  may  be  thus  traced  to  a  single  cow  or  a  single 
cook  or  dairyman.  More  often  the  people  originally  succumbing 
to  the  infection  infect  others  (usually  members  of  the  same  house- 
hold) and  the  numbers  increase  rapidly,  mainly  through  such  sec- 
ondary cases.  Eosenau  lists  over  4000  eases  of  milk-borne  diseases 
for  Boston  during  1907-11.2 

1907 — Diphtheria    72  cases 

1907 — Scarlet  fever   717  cases 

1908 — ^Typhoid  fever    about     400  eases 

1910 — Scarlet  fever .over     842  eases 

1911 — Septic  sore  throat over  2065  cases 

An  epidemic  in  New  York  City  including  over  400  cases  was 
traced  to  a  dairyman  who  had  had  typhoid  47  years  previously; 
one  in  Washington  was  traced  to  a  worker  who  had  had  typhoid  over 
40  years  previously. 

'The  present  milk  conditions  (pasteurization,  refrigeration,  etc.)  do  not 
provide  such  startling  figures  at  present,  fortunately. 


MILK  67 

Tuberculosis.— Cases  of  tuberculosis,  which  often  develop 
very  slowly,  cannot  be  rated  as  epidemics,  though  probably  similar 
wholesale  inoculations  of  patrons  occur.  No  figures  can  be  given 
for  the  human  type  of  tuberculosis  transmitted  by  milk  handlers 
who  have  the  disease.  We  can  indirectly,  however,  get  minimum 
figures  for  bovine  tuberculosis,  basing  them  solely  on  the  autopsies 
and  examinations  of  patients  showing  the  bovine  type  of  infection. 
The  examination  of  milk  for  tuberculosis  organisms  (Fig.  94)  will 
also  give  an  idea  of  the  danger  of  contracting  tuberculosis.  In 
each  of  several  large  cities  (New  York,  Chicago,  Eochester,  etc.) 
several  dozen  or  hundred  milk  samples  were  examined  recently  and 
tuberculosis  organisms  occurred  in  from  2  to  16  per  cent,  of  the 
samples. 

Children  are  more  susceptible  than  adults  to  bovine  tuber- 
culosis as  indicated  by  the  following  statements  made  by  various 
investigators : 

1.  At  least  7  per  cent,  of  the  infants  under  five  die  of  tuber- 
culosis contracted  from  milk ; 

2.  About  30  per  cent,  of  the  cases  of  tuberculosis  of  children 
under  five  are  due  to  the  bovine  type ; 

3.  About  30  per  cent,  of  the  tubercular  glands  {e.g.,  neck)  in 
children  under  sixteen  are  due  to  bovine  bacilli ;  some  investigators 
make  it  90  per  cent, ; 

4.  About  17  per  cent,  of  breast-fed  children  have  tuberculosis; 
35  to  40  per  cent,  of  those  fed  on  cow's  milk  have  tuberculosis. 

The  large  number  of  bacteria  found  in  milk  is  explained  in  part 
by  the  initial  sources,  which  are  numerous  and  varied.  The  bac- 
teria come  mainly  from  the  mouths,  hands,^  or  clothing  of  the 
milker;  from  the  manure,*  the  saliva,  or  diseased  organs — udder 
(Fig.  20),  adjacent  lymph-glands. — of  the  cow,  or  from  small  ani- 
mals, such  as  rats  or  flies,^  which  carry  dangerous  bacteria  on  their 

^  From  the  unwashed  hand  of  one  dairy  worker  45,000,000  bacteria 
were  obtained ;  washing  reduces  the  number  in  proportion  to  its  thorough- 
ness. 

■•A  strong  argument  for  strict  stable  cleanliness  is  found  in  the  evi- 
dence that  more  tuberculosis  organisms  enter  milk  with  the  manure  than 
through  a  diseased  udder. 

'  Over  a  million  bacteria  have  been  obtained  from  the  body  of  a  single 

fly. 


68  HOME  AND  COMMUNITY  HYGIENE 

bodies  {e.g.,  typhoid  from  privy  vault  visited  by  flies).  Besides  the 
list  already  given  there  are  many  other  possible  sources :  the  uten- 
sils, water  used  for  washing  the  utensils,  bacteria  (from  soil,  man- 
ure, etc.)  temporarily  suspended  in  the  air  (Fig.  31).  These 
sources  do  not  necessarily  include  bacteria  pathogenic  to  man,  but 


FiQ.  20. — Note  the  spongy  character  of  the  udder.     This  makes  it  practically  impossible 
to  rid  the  udder  of  invading  bacteria  which  gain  a  foothold  there. 

they  may,  nevertheless,  bring  about  undesirable  quality  changes 
already  described  as  occurring  in  milk. 

Temperature. — Not  only  is  there  opportunity  for  a  wide  range 
of  foreign  organisms,  but  these  bacteria  too  often  have  every  oppor- 
tunity for  rapid  multiplication.  On  milking,  the  temperature  of 
the  milk  is  about  that  of  the  human  body,  and  in  large  milk  cans 


MILK 


69 


(imless  cooled  quickly  by  ice)  this  temperature,  so  favorable  to 
organisms  pathogenic  to  man,  may  be  retained  for  several  hours. 
How  important  temperature  is  in  controlling  the  quality  of  milk 
is  shown  by  the  figures  for  one  single  sample  of  milk,  which  was 
divided  into  several  different  portions  and  kept  at  the  respective 
temperatures  indicated  (p.  70).  And  such  favorable  tempera- 
tures are  often  found  later  in  the  history  of  the  milk;  e.g.,  milk 
cans  waiting  in  hot  railway  platforms,  bottles  left  by  the  milkmen 


1 


M    ,    1  1  I  ,  I  ,  I  .  .  .      1 ,  ,  .  I 


Fig.   21. 


-Types  of  milk  pails  to  illustrate  that  relatively  few  bacteria  fall  into  pails  of 
approved  types. 


on  sunny  window  sills  for  late-rising  patrons,  and  milk  kept  in  hot 
kitchens  for  several  hours  before  using. 

Add  to  these  conditions  the  long  time  that  must  elapse  before 
milk  can  reach  its  final  destination.  A  short  time  ago  ^ew  York 
City  received  milk  from  eight  States  and  Canada.  Milk  delivered 
any  given  morning  at  a  New  York  City  house  was  often  three  days 
old;  add  to  that  one  to  two  days  for  the  time  period  in  the 
house,  and  it  will  be  seen  that  consumers  are  often  using  milk  five 
or  six  days  old.  Taking  also  into  consideration  the  rate  at  which 
bacteria  may  multiply  one  wonders  that  sweet,  good-tasting  milk 
ever  reaches  a  cit}'  dweller. 

The  combined  effect  of  time  and  temperature  on  bacterial  mul- 
tiplication is  illustrated  below.  Fresh  milk  (initial  count  3000 
organisms  per  c.c.)  was  divided  into  four  lots  which  were  kept  for 
ninety-six  hours  at  different  temperatures. 


70 


HOME  AND  COMMUNITY  HYGIENE 


Temperature 

Count  per  cubic  centimetre 

24  hours  later 

96  hours  later 

0°  C.  (32°  F.) 

2,400 

1,850. 

4°  C.  (39°  F.) 

2,500 

218,000. 

6°  C    (42°  F  )        

2,600 

500,000. 

10°  C.  (50°  F.) 

3,100 

300,000,000. 

20°  C.  (68°  F.) 

500,000,000.... 

Too  numerous  to  count. 

When  we  reflect  that  the  shelves  of  the  ordinary  home  refrig- 
erator are  often  10°  C.  (50°  F.)  we  can  see  that  the  best  place  for 
milk  is  in  the  ice  chamber  itself.  The  low  counts  which  were  ob- 
tained at  low  temperatures  during  the  first  twenty-four  hours  are 
explained  by  bactericidal  (G)  substances  in  the  milk;  at  high  tem- 
peratures the  resistant  bacteria  multiply  too  rapidly  for  this  bac- 
tericidal effect  to  be  noticed.  This  effect  disappears  in  time,  but  a 
temperature  near  freezing  keeps  the  bacterial  count  at  that  low  level. 
At  the  slightly  higher  temperature  of  the  ice  chamber  the  increase 
is  not  alarming.  Milk  should  be  rapidly  cooled  after  milking  and 
should  not  be  allowed  to  exceed  10°  C.  (50°  F.)  in  transit  or 
storage. 

Milk  Standards. — Considering  all  these  opportunities  for  con- 
tamination and  pollution,  one  wonders  that  we  ever  secure  clean 
and  safe  milk.  To  aid  in  doing  this  certain  standard  requirements 
are  usually  made.  These,  of  course,  are  minimum  requirements  re- 
garding milk  quality,  and  so  eliminate  only  the  poorest  or  most 
inferior  milk.  In  some  cities  these  standards  are  slowly  raised,  thus 
gradually  insuring  a  better  quality  of  milk,  without  too  great  in- 
justice to  the  smaller  milk  producers. 

Types  of  Standards. — ^The  standards  by  which  milk  can  be 
measured  are  (1)  physical  and  chemical,  e.g.,  temperature  (low 
enough  to  limit  bacterial  growth),  and  butter  fat  (which  should  be 
at  least  314  per  cent,  of  the  total  weight)  ;  (2)  bacteriological, 
limiting  the  total  number  of  bacteria,  and  to  some  extent,  the  kind 
(e.g.,  intestinal,  pathogenic)  ;  and  (3)  sanitary  standards,  relating 
to  the  conditions  under  which  milk  is  produced  (clean  utensils, 
stables,  etc.). 

Milk  adulteration  is  so  much  more  a  matter  of  lowering  the 
quality  (cream  removal,  addition  of  water)  than  the  addition  of 
deleterious  substances  that  it  vnll  be  treated  under  adulteration  in 


MILK  71 

the  chapter  on  foods  (p.  34).  It  is  sufficient  to  state  here  that  the 
old  tales  of  chalk  in  milk  are  usually  unfounded;  calves'  brains 
bring  too  good  a  price  to  use  them  as  an  adulterant,  and  as  Harring- 
ton points  out,  the  supply  is  too  limited  for  the  claim  to  be  worth 
serious  consideration.  Gelatin  has  been  detected  in  adulterated 
cream.  Chemicals  as  preservatives  are,  of  course,  illegal  in  any 
self-respecting  community. 

Methods  of  Testing  Physical  and  Chemical  Character. — 
There  are  several  different  types  of  apparatus  for  measuring  the 
physical  and  chemical  qualities  of  milk.  A  thermometer  *^  is,  of 
course,  used  in  determining  the  temperature  of  milk. 

The  total  solids  are  determined  in  various  ways,  but  the  methods 
are  all  based  on  one  of  two  things :  ( 1 )  evaporating  the  water  in  a 
given  quantity  of  milk  and  weighing  the  balance  left  after  the 
sample  has  been  completely  evaporated;  and  (3)  determining  the 
specific  gravity  (never  below  1.027  in  normal  milk)  and  correcting 
it  for  temperature  and  fat  content.  For  the  latter  method  such 
correction  is  necessary,  since  fat  is  lighter  than  the  other  milk 
solids,  and  its  removal  may  be  hidden  by  adding  sugar  to  give  the 
usual  total  solids;  such  adulteration  would  enable  a  dairyman  to 
sell  the  cream,  and  by  properly  adulterating  the  partly  skimmed 
milk,  pass  it  off  as  whole  milk.  The  effect  of  temperature  on  spe- 
cific gravity  is  also  important;  normal  milk  with  a  specific  gravity 
of  1.027  might  be  rated  higher  or  lower,  1.026  at  10°  C.  (50°  F.), 
or  at  1.028  at  20°  C.  (68°  F.),  thus  giving  incorrect  impressions  as 
to  its  possible  adulteration.  (Printed  tables  giving  such  equivalents 
are  used  for  this  determination.)  The  solids  are,  as  earlier  stated, 
mainly  sugar,  proteins,  and  fats.  The  first  two  vary  little  in  nor- 
mal milk,  and  if  tests  for  either  of  these  are  made  at  all,  it  is  usually 
for  sugar,  and  then  mainly  to  show  whether  additional  sugar  has 
been  added  to  cover  "  watering  "  or  cream  removal.  The  solids  to 
which  most  attention  is  paid  are  the  fats. 

Fat  Tests. — ^These  fat  tests  vary  greatly  in  details  and  in  the 
types  of  apparatus  used,  some  of  the  methods  and  apparatus  being 
very  complicated.  They  may  be  roughly  described  as  of  two  main 
types.     In  the  first  type  the  fat  is  completely  liquefied  and  sepa- 

°  The  thermometer  should  be  the  ordinary  milk  or  chemical  thermometer, 
with  the  registering  scale  on  or  in  the  mercury  tube.  Those  with  wopdeij 
backs  are  xisuallj^  not  accurate,  and  fire  pot  easily  cle£(,ned, 


72 


HOME   AND  COMMUNITY  HYGIENE 


rated  from  the  balance  of  the  milk.  This  is  done  by  adding  hot 
water  and  acid  and  by  centrifuging  (G).  This  is  usually  done  in  a 
glass  vessel  holding  a  definite  amount  of  milk  and  having  a  care- 
fully graduated  neck  (Fig,  22).  The  depth  of  clear  liquid  fat 
finally  collecting  in  this  neck  is  measured  and  translated  into  fat 
percentage  by  a  special  scale  on  the  neck  of  the  flask.  In  the  second 
method  of  fat  determination  a  given  weight  of  milk  is  thoroughly 


— g 

Li 

Fig.   22. — Babcock  tester,  with  detail  of  neck  on  left. 

mixed  or  washed  in  ether.  This  fat-absorbing  ether  is  then  taken 
off  into  a  separate  flask;  the  ether  is  allowed  to  evaporate,  and  the 
fat  contained  in  the  flask,  when  compared  with  the  weight  of  the 
whole  sample,  shows  the  per  cent,  of  fat. 

Bacterial  Content  of  Milk. — The  bacteriological  content  of 
milk  is  measured  in  several  ways.  These  methods  may  be  divided 
into  three  main  ones:  (1)  the  microscopic,  in  which  a  sample  of 
milk  is  placed  under  the  microscope  and  examined  for  the  kind  or 
number  of  bacteria  present;  (2)  the  "  plate  "  method  (G),  in  which 


MILK  73 

a  given  amount  of  milk  is  mixed  with  gelatin  or  agar  (G)  and 
allowed  to  stand  long  enough  for  the  bacteria  present  in  the  milk  to 
grow  into  visible  colonies;  and  (3)  the  inoculation  (G)  method,  in 
which  a  small  amount  of  milk  is  inoculated  into  an  animal  {e.g., 
guinea-pig),  and  the  subsequent  fate  of  the  animal  or  an  examina- 
tion of  its  blood  indicates  whether  or  not  pathogenic  bacteria  were 
present  in  the  milk  sample  used.  These  three  methods  are  described 
somewhat  more  in  detail  below. 

Microscopic  Examination. — The  microscopic  method  is  used 
for  two  purposes:  (1)  to  determine  the  presence  of  disease  and 
certain  disease-producing  organisms;  and  (2)  to  indicate  the  whole 
number  of  bacteria  present  in  the  milk.  In  the  first  the  examina- 
tion is  limited  mainly  to  a  search  for  white  corpuscles  and  for  two 
types  of  bacteria — streptococci  (G)  and  tuberculosis.  Some  white 
corpuscles  may  alv/ays  be  expected  in  unstrained  milk,  but  a  large 
number  indicates  disease  in  the  udder  or  adjacent  lymph-nodes. 
The  diseases  causing  such  an  overproduction  of  white  corpuscles 
(G)  are  sometimes  communicable  to  man  {e.g.,  septic  sore  throat 
and  tuberculosis).  Even  if  the  diseases  are  not  communicable  ones, 
we  would  not  knowingly  choose  such  milk,  and  milk  containing  a 
suspiciously  large  number  of  white  corpuscles  should  not  be  sup- 
plied to  unsuspecting  consumers.  Some  authorities  state  that  the 
number  in  normal  milk  may  even  reach  1,000,000  per  c.c. ;  and 
while  all  agree  that  they  are  greatly  increased  in  diseased  condi- 
tions of  the  udder  and  adjacent  glands,  few  agree  upon  the  upper 
limit  to  be  allowed  with  safety.  In  most  suspicious  cases  the  milk 
often  shows  an  undue  number  of  bacteria  also.  Streptococci  from 
the  human  mouth  or  from  septic  lesions  (G)  (sore  throat,  scarlet 
fever  throats,  abscesses),  or  from  the  cow  (saliva,  diseased  udder) 
are  usually  in  rather  long  chains,  often  twelve  to  forty  in  a  chain, 
and  sometimes  in  much  longer  chains.  The  streptococci  and  other 
coccus  organisms  from  other  or  non-animal  sources  are  rarely  in 
such  long  chains;  when  a  sample  of  milk  contains  long  chains  of 
coccus  organisms  it  should  be  looked  upon  with  suspicion.  Human, 
bovine,  and  equine  fecal  streptococci  are  often  of  the  long-chained 
type;  while  they  are  not  generally  considered  pathogenic  (G),  they 
may  be;  besides,  a  fecal  origin  is  not  a  pleasing  explanation  of 
their  presence,  and  would  not  be  tolerated  knowingly  by  any 
consumer. 


74  HOME  AND  COMMUNITY  HYGIENE 

Tuberculosis  organisms  may  be  demonstrated  in  milk.  They 
probably  do  not  multiply  rapidly  in  milk,  and  the  small  amount  of 
milk  that  can  be  examined  on  a  microscope  slide  might  not  contain 
any  of  the  organisms.  It  is  customary,  therefore,  to  centrifuge  (G) 
a  larger  sample  of  milk,  and  examine  the  sediment  thus  collected 
for  tuberculosis  organisms.  They  may  be  demonstrated  by  special 
staining  (G)  methods,  and  dangerous  milk  supplies  (whether  due 
to  tubercular  cows  or  to  tubercular  milkers)  may  be  thus  eliminated. 

The  preceding  methods  of  examining  milk  are  helpful  in  con- 
ditions where  disease  organisms  are  actually  present.  As  we  have 
already  seen,  milk  may,  however,  be  quite  changed  by  other  bac- 
teria, and  made  wholly  unfit  for  use  (sour  milk,  food  poisoning). 
The  number  of  bacteria  present  gives  some  indication  of  how  far 
these  changes  may  have  progressed.  There  are  two  common  ways 
of  determining  the  number  of  bacteria  in  milk :  the  microscopic  and 
the  plating  method ;  the  microscope  method  is  also  called  the  "  direct 
count "  method  to  distinguish  it  from  the  plating  or  "  plate  count " 
method  (G) ;  the  bacteria  are  counted  at  once  (directly)  without 
an  intervening  growing  period  as  in  the  plate  count  method.  A 
direct  count  is  made  by  placing  a  small  sample  of  the  milk  upon  a 
glass  slide,  staining  it  and  counting  through  the  microscope  the 
bacteria  seen  in  a  large  number  of  places  (fields)  on  that  slide.  If 
the  bacteria  average  per  field  is  low,  the  milk  can  be  classed  as  good 
milk;  if  the  average  is  higher  it  is  of  fair  or  poor  quality;  the 
actual  numbers  '^  vary  with  the  microscope  used  (Fig.  23). 

The  "plate"  method  (G)  is  the  oldest  and  is  still  the  one  most  generally 
used.  It  can  readily  be  seen  that  there  are  certain  disadvantages  in  each 
method  and  that  the  bacterial  counts  could  not  agree.  It  is  only  necessary 
to  find  the  equivalent  for  each  in  terms  of  the  other,  for  each  has  certain 
advantages  and  disadvantages  not  possessed  by  the  other  method.  In  the 
plate  method  all  the  bacteria  present  do  not  make  visible  colonies  in  the 
time  period  (2-3  days)  elapsing  before  the  plate  is  counted.  Some  of  the 
bacteria,   lacking  their   preferred   or  required   foods,   or   not   finding  their 

^  The  actual  number  of  bacteria  per  c.c.  can  be  estimated  by  determin- 
ing the  average  number  per  field,  and  mathematically  computing  the  actual 
size  of  the  field  and  the  number  of  such  fields  in  the  space  covered  by  the 
milk  as  spread  on  the  slide,  and  then  correcting  that  total  for  the  amount 
(part  of  a  c.c.)  used  in  making  the  slide.  If  a  pair,  a  chain,  or  a  mass  is 
counted  as  a  single  organism,  direct  counts  may  parallel  plate  counts ;  if 
each  organism  in  such  groups  is  counted,  the  direct  covmt  is  usually  two  to 
ten  times  the  plate  count.  Each  laboratory  must  determine  its  own  ratio, 
as  the  technic  employed  will  vary  somewbat. 


MILK 


75 


Fig  23  —Two  microscopic  pictures,  showing  good  and  poor  milk,  direct  count  method. 
The  large  dark  bodies  are  white  corpuscles. 


76  HOME  AND  COMMUNITY  HYGIENE 

optimum  conditions  of  oxygen  and  temperature,  do  not  grow  at  all.  The 
plate  method,  too,  gives  no  indication  of  the  dead  bacteria  in  the  milk.  In 
the  direct  count  method  dead  bacteria  may  stain  and  add  greatly  to  the 
bacterial  count;  groups  or  clumps,  if  counted  as  individuals,  increase  the 
direct  count.  This  is  not  necessarily  a  disadvantage,  as  we  are,  of  course, 
interested  in  all  the  bacteria  that  have  afl'ected  or  are  affecting  the  milk. 
The  plate  method  demands  more  expensive  material  (agar,  pipettes  and 
glassware)  and  more  labor  (sterilizing)  ;  it  also  takes  more  time,  and 
three  to  four  days  must  be  allowed  for  making  the  milk  plates,  incubating 
them,  counting  and  recording  the  results.  In  that  interval  the  milk  has, 
of  course,  been  consumed.  The  direct  count  demands  fewer  workers,  but 
these  must  all  be  of  higher  calibre,  e.g.,  skill  in  microscopic  and  staining 
technique  is  necessary.  The  small  sample  often  is  less  representative,  some 
claim.  The  count  can  be  quickly  made,  and  suspicious  or  poor  milk  held 
back  from  the  consumer.  It  also  gives  opportunity  for  making  a  strepto- 
cocci and  a  white  corpuscle  count,  showing  more  clearly  the  possibility  of 
disease  transfer. 

Accepted  Bacterial  Standards. — ^The  counts  allowed  on  agar 
plates  have  been  unnecessarily  high,  in  some  of  our  cities  as  high  as 
500,000  organisms  per  c.c.  It  is  gradually  being  lowered,  and 
while  30,000  is  considered  a  fair  standard,  there  is  no  good  reason 
why  properly  cooled  milk  should  exceed  6000  per  c.c.  in  winter  or 
12,000  in  summer. 

Sanitary  Standards. — Sanitary  standards  are — strange  to  say 
— the  most  recent.  They  are  based  on  the  observances  demanded 
by  common  decency  and  the  ordinary  standards  of  cleanliness. 
They  are  the  only  ones  easily  understandable  by  all  producers 
(farmers  and  dairymen),  and  they  have  been  emphasized  mainly 
with  the  idea  of  securing  the  full  cooperation  of  the  producers.  It 
is  astonishing  to  know  how  few  of  the  house  standards  "  carry  over  " 
to  the  barn.  In  the  house  no  one  would  put  fresh  milk  into  a  dirty 
pan,  drink  milk  into  which  a  mischief-making  person  threw  even  a 
tiny  particle  of  manure,  or  set  a  jDan  of  milk  where  it  would  catch 
house  dust  (sweepings).  Yet  it  has  long  been  quite  customary  to 
milk  into  dirty  pails;  and  most  farmers  feel  quite  abused  if  it  is 
even  suggested  that  strainers  or  straining  cloths  should  not  be  used. 
"How  else  is  one  to  take  out  the  bam  dirt  (cobwebs,  dust)  and 
manure  ?  "  they  ask,  with  the  air  of  having  settled  the  whole  ques- 
tion. That  dirt  should  be  kept  out  in  the  first  place,  does  not 
occur  to  them. 

Sanitary  standards  attempt  to  cover  more  than  mere  foreign 
matter.  The  health  of  the  cows  is  also  important,  and  so  besides 
sanitary  ruling.';  covering  the  stable  floor,   dust-making  processes 


MILK  77 

during  milking,  removal  of  excreta,  and  cleanliness  of  the  animals, 
the  standards  usually  consider  such  of  the  surroundings  as  affect 
the  cow's  health.  In  such  standards  we  iind  included  not  only 
tuberculosis,  foot-and-mouth  disease,  and  udder  infections,  hut 
minimum  ventilation  and  light  requirements.  The  following  score 
cards  indicate  the  sanitary  conditions  usually  demanded  (Figs. 
24  and  25). 

But  even  in  the  most  sanitary  of  surroundings  careless  milkers 
or  other  workers  may  produce  a  poor  and  even  filthy  milk.  Some 
investigators  feel  that  niiany  of  the  sanitary  requirements  are  not 
essential  to  clean  milk.  While  cement  floors,  extra  window  area, 
etc.,  may  affect  the  milk  supply,  they  evidently  do  so  to  a  less  degree 
than  the  relative  size  of  the  milk  pail  top  (Fig.  21),, soiled  hands 
sterile  utensils,  and  similar  details  that  can  be  changed  at  a  merely 
nominal  cost.  Milking  machines  are  variously  regarded  hj  dairy- 
men. They  are  difficult  to  keep  clean ;  if  kept  clean,  however,  a  low- 
count  milk  is  assured  without  so  much  attention  to  the  body  of  the 
cow,  room  conditions,  etc.  A  moist  sheet  with  an  opening  to  expose 
the  udder  can  be  used  at  milking  time ;  it  takes  less  time  than  wash- 
ing the  body  and  affects  the  cow's  skin  less  than  repeated  washings 
(eczema-like  eruptions). 

The  North  System. — By  insisting  upon  a  few  essentials :  "  dry 
milking,"  *  a  small-mouthed  pail,  prompt  cooling  and  prompt  de- 
livery of  the  milk,  and  having  the  returned  milk  cans  all  sterilized 
at  the  dairy  ready  for  the  next  consignment  of  milk,  a  clean  and 
low-count  milk  can  be  produced  even  in  poor  barns.  These  are 
summed  up  as  the  three  main  points :  method  of  milking,  cooling  the 
milk,  and  sterilizing  of  utensils  (Fig.  26).  This  does  not  mean 
that  the  health  of  the  cow  is  not  considered;  in  this  system  a  pre- 
mium (one-half  cent  a  quart)  is  paid  for  tuberculin-tested  cows. 
This  method,  it  is  claimed,  has  secured  a  good  quality  of  milk,  often 
averaging  below  the  10,000  to  25,000  per  c.c.  limits  set  by  the  re- 
ceiving stations. 

As  North  says,  milk'may  be  safe  because  it  has  been  boiled,  but 
still  indecent  because  it  is  filthy.     As  long  as  consumers  do  not  in- 

'  In  "wet  milking"  the  bands  are  moistened,  usually  with  the  fore  milk, 
as  some  milkers  feel  it  is  necessary  to  have  the  hands  wet  to  give  the  neces- 
sary ease  in  milking.  Saliva  is  even  more  undesirable  as  a  moistener,  and 
"dry  milking"  should  be  insisted  upon. 


78 


(Back  of  Card) 


Equipment 


cows 

Health 

Apparently  in  good  health 1 

If  tested  with  tuberculin  within 
a  year  and  no  tuberculosis  is 
found,  or  if  tested  w-ithin  six 
months  and  all  reacting  ani- 
mals removed 5 

Clf  tested  within  a  year  and  re- 
acting animals  are  found  and  re- 
moved, 3.) 

Food  (clean  and  wholesonae) 

T\'ater  (clean  and  fresh) 


Location  of  stable 

Well  drained 1 

Free   from   contaminating  sur- 
roundings   1 

Construction  of  stable 

Tight,  sound  floor  and  proper 

gutter. ....2 

Smooth,  tight  walls  and  ceilings  1 

Proper  stall,  tie,  and  manger.  .  .1 

Pro^-ision  for  light:    four  sq.  ft.  of 

glass  per  cow 

(Three  sq.  ft.,  3;  2  sq.  ft.,  2;  1  sq. 
ft.,  1.  Deduct  for  uneven  distri- 
bution.) 

Bedding 

Ventilation 

Pro\-ision  for  fresh  air,  control- 
able  fine  system 3 

(Windows  hinged  at  bottom, 
1.5;    sliding    windows,     1; 
other  openings,  0.5.) 
Cubic  feet  of  space  per  cow,  500 

ft 3 

(Less  than  500  ft.,  2;  less  than 

400  ft.,  1;  less  than  300  ft.,0.) 
Provision   for   controlling   tem- 
perature   1 


Construction  and  condition  of  uten- 
sils   

Water  for  cleaning 

(Clean, convenient, and  abundant.) 

Small-top  milking  pail 

Mlk  cooler 

Clean  milking  suits 


iQLK   BOOM   OB   MILK   HOrSE 

Location;  Free  from  contaminating 
surroundings 

Construction  of  milk  room 

Floor,  walls,  and  ceilings 1 

Light,  ventilation,  screens  .  . .  .1 

Separate  rooms  for  washing  utensils 
and  handling  milk 

Facilities  for  steam 

(Hot  water,  0.5.) 

Total 


Score 


Per-       Al- 
fect     lowed 


Methods 


COWS 

Qean 

(Free  from  visible  dirt,  6.) 


Cleanliness  of  stables 

Floor 2 

WaUs 1 

Ceilings  and  ledges 1 

Mangers  and  partitions 1 

Windows 1 

Stable  air  at  milking  time 

Freedom  from  dust 3 

Freedom  from  odors 2 

Cleanliness  of  bedding 

Barnyard 

Clean 1 

Well  drained 1 

Removal  of  manure  daily  to  50  feet 
from  stable 


MILK   BOOM   OB   MILK  EOCSE 

Oeanliness  of  milk  room 


UTENSILS   AND    MILKING 

Care  and  cleanliness  of  utensils 

Thoroughly  washed 2 

Sterilized  in  steam  for  15  min- 
utes  3 

(Placed. over  steam  jet,  or  scalded 

with  boiling  water,  2.) 

Protected  from  contamination.  .3 

Oeanliness  of  milking 

Clean,    drj'    hands 3 

L'dders   viashed   and   wiped.... 6 
(Udders  cleaned  with  moist  cloth, 

4;  cleaned  mth  dry  cloth  or  brush 

at  least  15  minutes  before  milking, 

1.) 

HANDLING   THE   MILK 

Oeanliness    of   attendants   in   milk 


room 

!MiLk    removed    immediately    from 

stable  without  pouring  from  pail.  . 
Cooled   immediately    after   milking 

each  cow 

Cooled  below  50°  F 

(51°  to  55°,  4;  56°  to  60°,  2.) 
Stored  below  50°  F 

(51°  to  55°,  2;  56°  to  60°,  1.) 
Transportation  below  50°  F 

(51°  to  55°,  1.5;  56°  to  60°,  1.) 

df  delivered  twice  a  day,  allow 
perfect  score  for  storage  and  trans- 
portation.) 


Total. 


Per-       Al- 
fect      lowed 


Equipment  -f Methods = Final   Score. 

Fig.  24. — Back  of  score  card  recommended  by  the  Dairy  Division  of  the  Bureau  of  Animal 
Industry,  U.  S.  Department  of  Agriculture. 


Date. 


MILK 
Dairy  of. 


79 


I.  Health  of  the 
herd  and  its 
protection 


n. 


Cleanliness  of 
the  cows  and 
thei  r  sur- 
roundings 


III.  Construction 
and  care  of 
the  utensils 


IV. 


Health  of  em- 
ployees and 
manner  of 
milking 


V.  Handling     the 
milk 


Health  and  comfort  of  the  cows  and  their  isola- 
tion when  sick  or  at  calving  time 

Location,  lighting  and  ventilation  of  the  stable . 
Food  and  water 


Total. 


Cows 

Stable. 

Barnyard  and  pasture 

Stable  air  (freedom  from  dust  and  odors) . 

Total 


Construction  of  utensils  and  their  cleaning  and 
sterilizing 

Water  supply  for  cleaning  and  location  and  pro- 
tection of  its  source 

Care  of  utensils  after  cleaning 

Use  of  small-top  milking  pail 


Total. 


Health  of  employees 

Clean  over-all  milking  suits  and  milking  with 

clean,  dry  hands , 

Quiet  milking,  attention  to  cleanliness  of  the 

udder  and  discarding  fore-milk 


Total. 


Prompt  and  efficient  cooling 

Handling  milk  in  a  sanitary  room  and  holding  it 

at  a  low  temperature 

Protection  during  transportation  to  market .  . .  . 


Total. 


Per- 
fect 


100 


30 
20 
20 
30 


100 


100 
45 
30 


100 


35 


35 
30 


100 


Score 


Total  of  All  Scores. 


500 


If  the  total  of  all  scores  is  And  each  division  is         The  sanitary  conditions  are 

480  or  above 90  or  above Excellent 

450  or  above 80  or  above Good 

400  or  above 00  or  above Medittm 

Below  400 Or  any  division  is  below  60 Poor 

The  sanitary 

conditions  are Scored  by 


Fi".   25. — Simpler  score  card  recommended  by  the  College  of  Agriculture,  Cornell  University 


80 


HOME  AND  COMMUNITY  HYGIENE 


sist  upon  having  what  Conn  calls  "  clean  milk,  not  cleaned  milk/' 
these  conditions  will  continue.     They  are  due  partly  to  ignorance, 


Fia.  26. — A  simple  way  of  sterilizing  a  millc  can.    A  large  flat  pan  filled  with  water  is  placed 
on  the  stove;  as  this  boils  steam  (under  slight  pressure)  fills  the  inveited  can. 

but  more  often  to  carelessness ;  and  the  opaque  liquid  character  of 
milk  helps  conceal  its  unsavory  past. 

Pasteurization. — Therefore,  because  we  cannot  feel  certain  that 
our  present  laws  secure  to  us  safe  milk,  pasteurization  is  growing  in 


MILK 


81 


popularity.     All  but  three  of  our  fifty  largest  cities  insist  upon 
pasteurization. 

Pasteurization  ^  is  a  process  which  involves  the  heating  of  milk 
to  a  sufficiently  high  temperature  to  kill  the  pathogenic  organisms 
most  often  found  in  milk.  In  pasteurizing  milk  on  a  commercial 
scale  the  milk  may  run  through  heated  pipes,  or  be  heated  in 
large  cans  or  tanks  (Tig.  27),  or  in  the  final  bottles.  Some  claim 
sufficiently  high  temperature  for  killing  pathogenic  organisms  and 

^THERMOMETOi 

tl 


M/IX 

ocm£T 


FiQ.  27.- 


-One  of  the  simplest  of  the  commercial  pasteurizers, 
an  even  temperature. 


A  revolving  paddle  insures 


neutralizing  some  of  the  bacterial  products  ^"^  may  be  ob- 
tained by  raising  the  milk  to  80°  C.  (176°  F.)  for  one  minute,  or 
simply  raising  it  to  81°  C.  (178°  F.)— the  "  flash "  methods. 
Most  workers  find  the  desired  results  only  certainly  and  uniformly 


'  It  is  so  named  because  it  is  practically  the  method  adopted  by  Pasteui 
in  wine  making  to  keep  down  the  growth  of  certain  undesirable  organisms. 

"Some  bacterial  ptomaines  and  toxins  (G)  survive  even  boiling. 
Pasteurization  cannot,  therefore,  take  the  place  of  cleanliness  during  milk- 
ing, or  low  temperatures  after  milking,  etc. 

6 


82  HOME  AND  COMMUNITY  HYGIENE 

obtained  by  raising  the  temperature  to  60°  C.  (140°  F.)  for  twenty 
to  thirty  minutes.  Klein  advocates  63.8°  C.  (145°  F.)  for  at  least 
thirty  minutes,  and  it  would  seem  wise  to  adopt  his  higher  and 
surer  temperature  and  time  standards. 

City  dwellers  are  usually  protected  by  local  regulations  demand- 
ing pasteurization.  In  less  densely  populated  districts  milk  is  often 
sold  in  a  raw  state.  If  there  are  no  legal  standards  requiring  pas- 
teurization, there  are  usually  none  regarding  bacterial  content.  In 
all  such  cases  it  may  be  necessary  to  pasteurize  the  milk  at  home. 
The  U.  S.  Department  of  Agriculture,  the  ISTew  York  City  Board 
of  Health,  and  other  reliable  authorities  have  issued  simple  direc- 
tions for  home  pasteurization  (see  Appendix). 

Objections  Made  Against  Pasteurizing  Milk. — Despite  a 
general  opinion  to  the  contrary,  pasteurized  milk  will  sour  quite 
normally,  and  it  is  used  by  several  large  firms  for  making  cheese  and 
butter.  If  milk  contains  an  unusual  number  of  protein-breaking 
bacteria  which  are  spore  (G)  producers,  pasteurization  may  leave 
an  unusual  proportion  of  these  behind,  and  as  they  develop  the  milk 
may  become  putrid,  slimy,  etc.,  instead  of  souring  in  the  usual  way. 
It  is  probable  that  only  the  poorest,  or  least  clean,  milk  is  so  affected 
by  pasteurization. 

Pasteurized  milk,  it  was  once  feared,  might  be  passed  off  as  high- 
grade  raw  milk,  without  detection,  as  it  gives  a  low  plate  count, 
etc.  But  there  are  two  checks  on  such  dishonest  practices:  (1) 
characteristic  enzymes  (G)  may  be  killed  if  pasteurized  at  high  tem- 
peratures, at  79°  to  80°  C.  (174°  to  176°  F.)  ;  another  check  is 
found  in  the  fact  that  the  white  corpuscles  (G)  are  changed, 
(heated  white  corpuscles  stain  less  readily  and  are  smaller  in  size). 

The  other  chief  objection  to  pasteurization  is  that  it  changes  the 
nutritive  quality  of  the  milk.  Malnutrition,  scurvy,  and  general 
digestive  difficulties  have  been  attributed  to  such  heated  milks;  and 
it  is  also  claimed  that  such  heating  renders  essential  food  elements 
insoluble,  kills  necessary  enzymes,^^  and  destroys  the  vitamines  (see 
p.  27).  The  following  thermometer  (Fig.  28)  shows  the  relative 
temperatures  at  which  these  changes  really  occur — decidedly  above 
the  recommended  and  customary  pasteurizing  temperatures. 

"There  may  be  some  loss  in  ordinary  milk  enzymes  (diastase,  galactase, 
oxydase,  etc.).  It  is  doubtful  if  these  are  really  serious,  though  most 
experts  think  it  wiser  to  retain  them. 


MILK 


Hb 


ib7 


IJ8- 
154.4- 


Bl5^eMrizofToTl  wifh 

TwaTgiTi  of  safety 

30-4 J  MIN 


(5  0- 

14a- 


>    145 


140- 


133 


83 


s 


—   80      Peroxidase   Killed 


■7^ 


^^'Reduct'ase  cha-nties  bepi-n  (JO-SO 

—  70 Ger-micida)   £<choTi    deslroyed 

b83     Soluble   phosphahss    ftffecfed 

-  fc8      CaMase.  Killed 


-bJj-t       CoadulafTo-n    be #1714 

•b5         Dias^a«e   chi^nrfes    be  fin  (t5-t8) 

-   (92.8     Tuberculosis     Killed 


iQ       5^rep^oco<:ci^     typhoid, 

arid  diphtlieria    Ki'lled 


->5't  Gerrnicldal    flcr/on   weaKencd 


o 


Fig.  28. — This  thermometer  shows  the  relation  of  various  heat  changes  in  milk  to 
the  pasteurizing  temperature.  Both  Centigrade  and  Fahrenheit  temperatures  are  given 
(see  Appendix). 

Since  milk  is  pasteurized  to  render  it  safe,  great  care  must  be 
taken  to  see  that  the  treatment  following  pasteurization  does  not 
annul  the  benefits  of  pasteurization.     The  milk  should  be  cooled 


84 


HOME  AND  COMMUNITY  HYGIENE 


quickly  and  kept  below  10°  C,  (50°  F.)  until  used  or  delivered. 
Careless  handling  during  bottling  should  be  guarded  against;  this 
presupposes  using  sterilized  bottles  and  capping  or  sealing  by 
machinery. 

Part  of  the  prejudice  against  pasteurization  is  due  to  the  fact 
that  it  was  originally  advocated  to  delay  the  spoilage  of  milk  ahd 
that  it  may  mask  careless  or  filthy  methods.  That  is  undoubtedly 
true,  but  as  long  as  the  community  thinks  it  cannot  afford  to  pay 
the  higher  price  of  producing  a  sanitary  though  unheated  milk,  and 
as  long  as  inspection  of  the  widely  distributed  farms  that  supply 
our  milk  is  as  inadequate  as  it  is,  it  is  the  only  safe  method. 

Pasteurized  Milk  for  Babies. — Physicians — even  those  with 
bacteriological  training — often  express  violent  prejudices  against 
pasteurized  milk.  This,  however,  is  not  supported  by  the  results 
obtained  in  infant  welfare  work  (see  p.  27  and  289). 

Still  more  convincing  is  the  following  report  by  Park  and  Wil- 
liams, based  on  a  series  of  observations  on  nearly  one  hundred 
children. 


Type  of  milk 

No. 
infants 

No.  well  all  summer 

No.  ill  (diarrhcBa) 

Average 

weekly 

gain 

Deaths 

Pasteurized 

milk 

Raw  milk .  .  . 

41 
51 

31  (75  per  cent.) 
17  (33  per  cent.) 

10  (24  per  cent.) 
33  12  (64  per  cent.) 

4  oz. 
3.5  oz. 

1 

2  '2 

Children  over  three  and  adults  can  use  raw  milk  with  consid- 
erably less  danger  of  diarrhoea  and  dysentery.  Adults  are  also  less 
susceptible  to  bovine  tuberculosis.  These  facts  do  not  militate 
against  pasteurization,  because  septic  sore  throat,  diphtheria,  scarlet 
fever,  and  typhoid,  so  commonly  spread  by  milk,  attack  all  ages. 

Milk  Quality. — In  other  foods  consumers  are  willing  to  pay 
for  higher  aualitv.  In  canned  goods,  package  foods,  and  un- 
labelled  foods — meats,  eggs,  vegetables,  dried  and  fresh  fruits — we 
unhesitatingly  pay  the  excess  demanded  for  high-grade  goods. 
MacISTutt  rightly  asks  why  we  accept  four  or  five  grades  for  eggs 
and  are  generally  contented  with  but  one  grade  of  milk — certified 
milk  excepted  for  a  small  percentage  of  the  consumers.    It  must  be 

"  Thirteen  of  the  children  were  transferred  to  pasteurized  milk  because 
of  serious  illness.  The  figures  would  doubtless  be  more  markedly  in  favor 
of  pasteurized  milk  otherwise. 


MILK 


85 


admitted,  however,  that  to  most  people  "  milk  is  milk,"  and  quality 
— except  the  "  cream  line  " — is  not  considered  at  all. 

Market  Standards. — Definite  standards  have  been  demanded  by 
alert  committees.  The  reports  of  the  Commission  on  Milk  Stand- 
ards have  been  important  in  shaping  the  standards  of  many  locali- 
ties, since  they  have  been  indorsed  by  the  American  Public  Health 
Association  and  the  American  Medical  Association.  They  are  given 
(in  a  somewhat  condensed  form)  below: 


Grade  A: 


Raw. 


Cows  free  from  disease . 


Pasteurized . 


f  Tuberculin-tested  (G) 
\  Examined  by  veterinarian. 
Workers  (with  milk  and  cows)  free  from  disease  deter- 
mined by  medical  inspection. 
Sanitary  conditions  good. 

Bacterial  count  not  above  10,000  per  c.c.  at  time  of 
delivery. 

Cows  free  from  disease — examined  by  veterinarian. 

Sanitary  conditions  good. 

Bacterial  count  not  above  200,000  at  any  time  before 

delivery. 
Pasteurized  (official  supervision)  and  count  not  above 

10,000  at  delivery. 

iCows  free  from  disease — examined  by  veterinarian. 
Sanitary  conditions  good. 
Bacterial  count  not  above  1,000,000  per  c.c.  before  pas- 
teurization; 50,000  at  time  of  delivery. 

Cows  free  from  disease — physical  examination. 
Includes  all  milk  with  bacterial  count  exceeding  1,000,000 

per  c.c. 
Bacterial  count  less  than  50,000  per  c.c.  when  delivered 

to  consumer. 
(.Restricted  to  cooking  and  manufacturing  purposes. 

(Classified  in  same  grades  as  milk  excepting  bacterial 
standards,  which  vary  in  proportion  to  fat;  e.g.,  in 
18  per  cent,  cream  it  must  not  exceed  5  times  that  for 
the  same  grade  of  milk. 

There  are  several  favorite  terms  for  milk  used  by  various  dairy 
companies:  select,  selected,  guaranteed,  inspected,  certified,  baby- 
milk,  etc.  Unless  the  firm  using  any  one  of  these  terms  can  give  a 
definite  meaning  for  the  term  used,  and  support  it  by  specific  ref- 
erence to  legal  standards  demanded  by  the  State,  city,  or  local 
health  boards,  the  term  may  be  absolutely  meaningless.  For  ex- 
ample, inspected  would  not  necessarily  mean  inspected  by  a  veteri- 


Grade  B: 

Pasteurized  only 

Grade  C: 
Pasteurized  only 

Cream 


Certified  milk . 


86  HOME  AND  COMMUNITY  HYGIENE 

narian  nor  for  tuberculosis,  but  merely  that  a  member  of  the  dairy 
firm  inspects  the  farm  (most  casually  even)  once  a  year  or  so. 
Cpnsumers  should  not  pay  fancy  prices  for  milk  without  full  return 
in  food  content,  and  in  freedom  from  bacterial  infection  and 
decomposition. 

The  only  special  term  of  fairly  uniform  meaning  throughout  the 
United  States  is  "  certified "  milk.  The  word  "  certified "  was 
apparently  coined  by  Doctor  Coit,  of  Newark,  N.  J.,  in  an  en- 
deavor to  secure  a  safe,  high-grade  milk  for  babies.  It  has  been 
adopted  by  the  American  Association  of  Medical  Milk  Commissions, 
and  is  legally  protected  in  a  number  of  States.  In  such  States  it 
means  milk  produced  under  good  sanitary  conditions  by  a  producer 
who  has  entered  into  an  agreement  with  a  medical  milk  commission 
to  fulfill  its  requirements ;  in  return  the  producer  is  allowed  to  use 
the  term  "  certified."  The  requirements  are  most  detailed ;  food, 
sanitary  conditions,  the  milkers,  age  of  milk  when  delivered,  etc. 

'  Highest  quality  of  raw  milk  (fat,  protein). 
From  tuberculin-tested  cows. 
Bacteria   Limited   to    10,000   per   c.c.   when   delivered 

(bacterial  examination  made  weekly). 
Sanitary  conditions." 

How  far  we  are  as  a  country  from  a  thoroughly  good  milk 
supply  may  be  seen  from  the  fact  that  MacISTutt  estimates  the  total 
production  of  certified  milk  to  be  but  25,000  gallons  daily  for  the 
whole  United  States — less  than  1  per  cent,  of  the  whole  milk 
supply.  An  incentive  to  the  production  of  clean  milk  which  con- 
sumers are  slow  to  award  is  an  increase  in  price  suflBcient  to  repay 
the  producer  for  the  increased  outlay  of  time  and  money.  Put 
thus  plainly,  it  is  difficult  to  see  how  one  could  hesitate.  Pure,  clean 
milk  cannot  be  produced  as  cheaply  as  can  dirty  milk.  As  long  as 
we  continue  to  ignore  differences  in  milk  quality  and  refuse  to  pay 
a  fair  price  for  the  time  and  labor  necessary  to  produce  clean  milk, 
we  will  continue  to  have  but  one  grade  of  milk,  and  that  a  poor  one. 

Milk  is  expensive  to  produce.  In  an  eastern  milk  station  the 
estimated  cost  of  keeping  one  cow,  including  her  share  of  the  barn 
and  other  overhead  charges  (which  any  good  business  man  would 
consider  but  fair),  ranged  from  $85  to  $165  per  year.     The  pro- 

"Tlais  is  open  to  very  loose  interpretation,  of  course,  and  such  laxity 
is  but  partly  counteracted  by  the  low  limit  for  bacteria. 


MILK  87 

duetion  cost  per  quart  ranges  from  3.5  cents  to  4.5  cents.  In 
country  towns  in  this  same  State  milk  retails  for  six  cents  a  quart 
(March,  1918).  The  price  paid  at  the  collecting  station  is  consid- 
erably lower.  It  can  be  readily  seen  that  the  farmer  has  but  a  small 
margin  of  profit;  many  farmers  have  found  (on  establishing  com- 
petent book-keeping  methods)  that  they  have  been  selling  milk  at  a 
decided  loss.  We  must,  therefore,  expect  to  pay  a  high  price  ^*  for 
milk.     A  fair  price  is  bound  to  be  a  high  price. 

Publishing  the  test  results  (fat,  bacteria,  etc.)  helps  in  an  in- 
telligent community  or  in  the  smaller  towns  where  the  consumer 
can  connect  such  reports  with  the  respective  producers.  In  certain 
localities  milk  has  a  certain  price  as  milk:  but  a  substantial  pre- 
mium is  paid  for  excess  butter  fat;  low  bacterial  count  (under 
10,000  per  c.c),  and  for  milk  from  tuberculin  tested  cattle. 

The  following  milk  bill  issued  at  one  of  the  Korth  collecting 
stations  shows  a  premium  of  $37  on  $191 — nearly  20  per  cent. — 
enough  to  make  any  farmer  "  take  notice."  Note,  however,  that 
it  raised  the  price  but  eight  mills  per  quart.  What  consumer  would 
not  pay  that  extra  eight-tenths  of  a  cent  cheerfully? 

New  Yoek  Dairy  Demon steation  Co.,  Homer,  N.  Y.,  to  Mr.  Blank,  Dr. 

1912. 

Dee.  1.     To  4500  quarts  of  milk  at  414c $191,25 

To  premium  butter  fat  3.9  per  cent,  at  2c 9.00 

To  [premium]  tuberculin  test  at  %c 16.87 

To  [low  count  premium]  bacteria  at  14c 11.25 

Total   $228.37 

MILK   PEODUCTS 

Preparations  Involving  Loss  of  Water. — An  earlier  table 
(p.  63)  has  given  the  standard  composition  of  milk  products  that 
are  sold  as  evaporated  milk,  condensed  milk,  etc.  These,  including 
milk  powders,  by  the  various  processes  of  profitable  preparation — 
whole  or  partial  evaporation  of  the  contained  water  at  high  tem- 
peratures— are  usually  freed  from  bacteria.     The  water  may  be 

"  In  milk,  as  in  many  other  foods,  the  middleman  seems  to  make  an 
unfair  share  of  the  profit.  In  the  case  above  mentioned,  while  milk  was 
retailing  in  the  farm  neighborhood  for  six  cents  a  quart,  the  same  milk 
retailed  in  the  nearby  city  for  sixteen  cents  a  quart.  It  seems  clear  that 
the  farmer  has  too  little  part  of  this  sixteen  cent  selling  price  for  his  labor 
and  for  the  money  invested. 


88  HOME  AND  COMMUNITY  HYGIENE 

evaporated  by  boiling,  but  more  often  is  removed  by  spraying  the 
milk  in  finely  divided  amounts  into  a  heated  chamber  or  tank. 
The  addition  of  sugar  to  sweetened  ("condensed")  milk  adds  to 
its  keeping  quality.  If  too  high  temperatures  are  used,  the  sugar 
caramelizes,  and  various  brownish  colors  result,  depending  upon 
the  degree  of  change  of  sugar  to  caramel.  Consumers  receiving  such 
overheated  cans  are  often  unduly  distressed  over  "  spoiled  "  milk. 
The  hj'gienic  problems  connected  with  such  milks  are,  therefore, 
mainly  those  of  adulteration  (sugar  for  bulk,  etc.).  It  is  not 
thought  that  the  vitamines  are  greatly  affected  in  such  partly- 
evaporated  or  even  dried  milks.  For  baby-feeding,  these  are  valuable 
substitutes  if  fresh,  safe,  whole  milk  cannot  be  obtained. 

Soured  Milk  Drinks. — Among  the  soured  milk  products  are 
several  types  known  locally  or  commercially  as  Metchnikoff  milk, 
fermillac,  lacto-bacillas,  matzoon,  koumiss,  and  by  many  other 
names.  These  are  milk,  usually  cow's  milk  in  this  country,  in 
which  special  organisms  ^^  have  developed,  and  formed  a  high  per- 
centage of  acid,  often  4  per  cent.  (Most  bacteria  normally  souring 
milk  cease  their  activity  after  the  amount  of  acid  reaches  about  1 
per  cent.)  The  organisms  causing  the  higher  amount  of  acid  are 
transferred  from  one  lot  of  soured  milk  to  another  lot  of  sweet  milk 
in  various  ways.  A  spoonful  may  be  used  as  a  starter ;  some  firms 
sell  tubes  of  liquid  or  tablets  containing  these  bacteria;  in  some 
countries  strings  dipped  in  the  sour  milk  are  dried,  and  later  used 
to  inoculate  the  next  lot  of  milk ;  "  kefir  grains  "  are  tiny  masses 
of  these  organisms  (besides  the  bacteria  distributed  as  usual  through 
the  milk,  large  numbers  adhere  in  these  so-called  "  grains "  or 
"bee-bread  ").  In  very  warm  countries  where  ice  is  practically  un- 
known and  milk  changes  would  progress  rapidly,  large  amounts  of 
harmful  protein-decomposition  products  may  result.  Since  most  of 
the  bacteria  causing  such  undesirable  products  do  not  grow  rapidly 
in  the  presence  of  acid,  soured  milks  are  quite  free  from  harmful 
accumulations.^^  In  Arabia,  Armenia,  and  other  warm  countries, 
sour  milk  is  a  favorite  drink;  and,  in  fact,  in  some  localities  sweet 

"These  are  usually  bacteria:  sometimes  pure  cultures  are  used,  some- 
times a  mixture  of  two  or  even  more  organisms.  In  some,  yeasts  and  even 
molds  are  present. 

^*  WTiile  usually  true,  at  least  one  epidemic  has  been  traced  to  butter- 
milk. 


MILK  89 

milk  is  not  used  at  all  unless  it  is  cooked.  Such  fermented  milks 
are  more  easily  digested  than  the  curds  of  ordinary  sour  milk. 

Eecently,  soured  milks  have  been  much  advertised  as  having 
other  valuable  qualities:  (1)  that  the  acid  contained  (or  else  formed 
later  in  the  intestine)  is  unfavorable  to  certain  undesirable  bac- 
teria— disease  organisms,  such  as  typhoid  and  many  forming  poison- 
ous proteins;  and  (2)  because  of  the  inhibiting  action  just  de- 
scribed they  improve  the  general  health  and  so  prolong  life  itself. 
Acting  on  this  general  theory,  typhoid  patients  are  often  promptly 
put  on  a  sour  milk  diet."  Besides  the  known  digestive  advantages 
of  such  soured  milk  the  contained  organisms  may  displace  and  in- 
hibit the  typhoid  bacteria. 

A  large  number  of  people  seem  to  be  benefited  by  a  sour  milk 
diet;  this  probably  is  not  wholly  due  to  the  above  (Metchnikoff) 
theory,  but  partly  to  a  difference  in  food  values.  At  present  yeast  is 
sometimes  prescribed  instead. 

Butter. — Butter,  another  milk  product,  interests  us  mainly 
from  the  point  of  adulteration.  That  is  discussed  in  the  chapter 
on  foods  (see  p.  34).  In  the  old  way  of  butter  making  the  bac- 
teria present  cause  the  souring  of  the  milk  before  the  cream  is 
skimmed;  in  most  creamery  methods  certain  types  of  bacteria 
(starters)  are  put  into  the  separated  cream  to  bring  about  de- 
sired taste  or  flavor  changes.  Unusual  or  undesirable  types  cause 
bitter,  rancid,  fishy,  or  other  tastes  in  butter.  The  ease  with  which 
butter  absorbs  odors  may  lead  one  to  think  a  butter  dangerous, 
when  one  is  really  smelling  or  tasting  the  wood  of  the  butter  tub  or 
the  turnips  in  the  kitchen  ice  box.  In  certain  French  and  Swiss 
localities  pleasing  butter  flavors  are  assured  by  placing  the  butter 
near  violets,  tuberoses,  and  similar  sweet-scented  plants.  Disease 
organisms  present  in  the  milk  may  be  found  in  butter  and  cheese 
made  from  that  milk.  Well-known  firms  are,  therefore  adver- 
tising butter  and  cheese  made  from  pasteurized  milk.  This  proves 
the  falsity  of  the  popular  belief  that  pasteurized  ^'^  milk  will  not 
sour.  With  the  use  of  butter  and  cheese  starters,  good  butter  and 
several  types  of  cheese  have  been  made  from  pasteurized  milk  by 
the  Dairy  Division  of  the  Department  of  Agriculture. 

"  Clean  milk  sours  quite  normally.  Milk  containing  an  unusual  pro- 
portion of  spore-forming,  protein-breaking  bacteria  may  not  sour  in  the 
usual  way;  such  milk  is  usually  filthy  milk. 


90  HOME  AND  COMMUNITY  HYGIENE 

While  it  is  difficult  to  secure  any  figures  showing  that  tuber- 
culosis, typhoid  or  other  diseases  are  caused  by  butter/®  examina- 
tion of  butter  has  recently  shown  tuberculosis  present  in  2  to  5  per 
cent. — rarely  in  10  per  cent. —  of  the  samples  examined.  A  similar 
but  harmless  organism,  presumably  from  water,  is  sometimes  con- 
fused with  tuberculosis  organisms.  The  small  amount  of  water 
in  butter  means  a  rather  high  salt  percentage;  this  has  a  deterrent 
action  on  bacteria  and  increases  its  "  keeping  "  quality.  The  vari- 
ous types  of  butter  and  cheese  have  little  hygienic  significance,  their 
differences  from  that  point  being  mainly  a  matter  of  difference  in 
flavor  and  relative  food  value  (skim  milk,  whole  milk,  etc.).  For 
the  methods  of  making  butter  and  cheese,  consult  the  references  for 
this  chapter. 

Renovated  Butter. — Eenovated  butter  might  be  mentioned 
here,  as  our  interest  in  that  is  not  the  same  as  in  siueet  or  fresh 
butter  or  in  the  types  of  cheeses.  Long-soured  or  old  milk  or  rancid 
butter  may  be  treated  to  remove  objectionable  accumulated  sub- 
stances: aerated  to  remove  odors,  treated  with  lime  to  counteract 
acid  and  redissolve  the  casein,  washed  to  remove  rancidity,  and, 
finally,  colored,  rechurned,  and  good,  pleasing  butter  secured. 
There  is  little  indication  that  it  is  harmful  to  consumers.  Eeno- 
vated butter  is  not  lacking  in  vitamines. 

Cheese. — The  only  other  milk  product  of  hygienic  importance 
is  cheese.  As  indicated  under  adulteration,  labels  should  state 
whether  the  cheeses  are  made  from  milk  with  cream  additions, 
whole  milk,  or  skim  milk.  Other  additions  should  be  indicated — 
such  as  bean  meal,  bread  crumbs,  potatoes,  and  lard.  Such  addi- 
tions class  the  cheeses  as  "  filled  cheese."  Lard  is  the  only  common 
addition  in  this  country.  The  United  States  standard  asks  for  50 
per  cent,  milk  fat,  but  good  grade  American  cheeses  usually  contain 
about  36  per  cent,  fat,  30  per  cent,  protein,  4  per  cent,  salt,  and 
the  balance  of  water. 

Food  poisoning  is  less  often  due  to  cheese  than  to  milk 
itself.  As  in  butter  making,  the  early  acid  stages  discourage  the 
growth  of  most  protein -breaking  bacteria.    The  work  of  the  Bureau 

"  It  is  usually  impossible  to  trace  the  butter  back  to  the  contributing 
cow.  The  long  latent  or  incubation  period  of  tuberculosis,  the  varied 
sources  of  typhoid  carriers  (water,  milk,  unwashed  vegetables),  often  make 
it  almost  impossible  to  trace  the  cause  of  such  diseases. 


MILK  91 

of  Animal  Industry  (p.  89)  indicates  that  high-grade  cheeses  can 
be  made  from  pasteurized  milk.  The  danger  of  food  poisoning  is 
thereby  lessened.  Some  thirty  years  ago  over  300  cases  of  "ptomaine 
poisoning^'  in  Michigan  occurred  in  less  than  two  years.  The 
danger  from  cheese,  nevertheless,  is  not  great. 

Cheese  made  from  pasteurized  milk  ■vrill  not  convey  the  ordinary 
disease  organisms.  Fresh  cheeses  (cream  cheese  or  cottage  cheese) 
may  hold  tj^phoid  from  five  to  twelve  days.  Some  cheeses  take  sev- 
eral months  to  ripen ;  a  few  as  long  as  three  or  four  years  I  These 
are  quite  unlikely  to  convey  pathogenic  organisms. 

PROBLEMS 

1.  What  legislation  protects  your  milk  supply? 

2.  What  reasons  have  you  for  thinking  this  legislation  is  not  enforced? 

3.  What  changes  do  you  think  desirable  for  the  consumer  ? 

4.  Is  the  price  of  milk  in  your  community  fair  to  the  farmer?  to  the 
milk  dealer  ?  to  the  consumer  ?     What  can  you  do  about  it  ? 

5.  What  special  terms  ( inspected,  certified,  etc. )  are  used  in  your 
locality?     Which  have  legal  standing?  definite  meaning? 

6.  Write  a  farmer's  bulletin  presenting  to  him  forcibly  and  clearly 
the  hygienic  phases  of  the  milk  problem  from  the  consumer's  point  of  view. 

7.  What  are  the  things  concerning  milk  you  would  cliange  on  the 
farm  you  know  best  ? 

8.  How  can  a  safe  raw  milk  or  a  clean  pasteurized  milk  be  secured  for 
all  the  babies  in  your  community? 

9.  Has  your  community  any  standards  for  ice  cream  (addition  of 
lard  or  gelatin,  bacterial  count,  cleanliness  of  utensils)  ? 

10.  Write  a  clear  statement  of  how  each  housekeeper  should  care  for 
or  treat  the  kind  of  milk  available  in  your  community.  Include  as  many 
of  the  following  points  as  the  type  of  milk  supply  (raw  or  pasteurized. 
loose  or  bottled)  makes  necessary:  temperature,  washing  and  scalding  of 
bottles,  pails  or  pitchers,  covering  to  keep  out  dust  or  flies,  and  home 
pasteurization. 

11.  Send  to  the  Children's  Bureau  at  Washington  for  Mendenhall's 
pamphlet  on  Milk.  Note  the  advantages  of  dried  milk  over  other  prepared 
milks.     \Mien  would  you  recommend  dried  milk  for  babies? 

12.  Write  in  concise  form  definite  answers  to  all  the  arguments 
against  pasteurized  milk. 

13.  Debate  ""Pasteurization  as  a  necessary  safeguard  of  all  city  milk 
supplies." 

See  Reference  List  at  end  of  Appendix. 


>  CHAPTEK  Y 

WATER 

The  important  part  water  plays  in  our  present  methods  of  liv- 
ing is  wholly  unappreciated  by  most  of  us.  As  in  the  case  of  air, 
if  we  think  of  it  at  all,  it  is  as  a  natural,  limitless  part  of  our  en- 
vironment about  which  we  need  "take  no  thought."  It  takes  a 
frozen  water  main  or  a  summer  in  an  isolated  camp,  necessitating 
our  personal  services  as  "  carriers  of  water  "  for  house  and  personal 
uses,  to  jog  us  into  a  realization  of  its  many  uses,  or  to  make  us 
see  that  it  is  possible  to  decrease  materially  the  large  amounts  we 
carelessly  assume  to  be  absolutely  necessary. 

Uses  of  Water. — Occasionally  a  ruminating  mind  wonders 
vaguely  at  the  universal  uses  of  water :  its  value  as  a  liquid  carrier 
of  nutrients  for  both  plants  and  animals;  its  universal  solvent 
action,  absorbing  oxygen  ^  from  the  air  and  making  life  in  its 
depths  possible,  extracting  needful  substances  from  the  soil,  or  mak- 
ing possible  the  cleansing  of  floors,  dishes,  and  clothing;  its  histori- 
cal and  biological  effects  on  the  vast  areas  of  land  it  has  separated 
for  centuries;  or  its  continuous  circulation  between  sky  and  earth, 
with  the  resultant  climatic  effects. 

But  its  role  in  health  and  sanitation  is  rarely  dwelt  upon  con- 
sciously; and  when  it  is  the  subject  of  consideration  our  main  in- 
terest is  rather  in  the  amounts  consumed  than  in  the  amount 
essential  to  health  from  the  physiological  or  the  h3fgienic  stand- 
point. Its  uses  in  the  body  may,  perhaps,  be  summarized  here  (1) 
to  show  that  a  certain  amount  is  absolutely  necessary  and  (3)  to 
emphasize  the  fact  that  because  of  the  intimate  associations  the 
quality  of  that  supply  is  most  important. 

Water  in  Relation  to  the  Human  Body. — In  the  human  body, 
water  fills  a  most  important  office.     At  least  70  per  cent,  of  the 

*It  is  interesting  to  know  that  the  "air"  in  water  differs  in  its  com- 
position from  that  which  ordinarily  surrounds  us;  it  contains  35  per  cent, 
of  oxygen  instead  of  the  usual  21  per  cent.  Evei-y  gas  (and  water  absorbs 
to  some  degree  every  known  gas)  is  absorbed  separately  and  according  to 
its  respective  "'solubility." 

92 


WATER  93 

body  weight  is  water;  water  enters  into  the  chemical  composition 
of  the  cells;  it  keeps  the  cell  surfaces  moist,  not  only  on  exposed 
membranes,  mouth,  nasal  cavity,  etc.,  but  even  in  the  deeper  tissues, 
for  all  living  cells  are  in  contact  with  a  water-bearing  medium 
(blood  or  lymph)  making  possible  the  characteristic  pliability  and 
elasticity  of  the  muscles  and  tendons ;  it  is  a  solvent  for  foods  and 
gases — a  most  important  function,  as  no  substances,  even  gases, 
enter  or  leave  the  living  cells  except  in  solution ;  water  also  forms  a 
medium  (blood,  lymph)  for  distributing  body  heat,  and  by  its 
excretion  in  considerable  amounts  (lungs,  kidneys,  and  skin)  it 
helps  to  maintain  normal  body  temperature. 

Source  of  Body-water. — The  oxidation  of  foods  yields  a  part 
of  the  water  needed  by  the  body,  e.g.,  sugar  utilized  in  the  body 
forms  water  (C3H,A)+0i2  ^Q{CO^)  ^  Q{11^0).  A  small 
amount  enters  the  body  in  the  semi-solid  or  even  in  the  so-called 
solid  foods  (a  little  more  than  a  pint  or  about  half  a  litre).  The 
balance  must  be  taken  as  water,  at  least  two  quarts  daily. 

Different  Classes  of  Water. — As  stated  before,  this  intimate 
and  general  use  of  water  in  the  body  indicates  that  the  kind  of 
water  supplied  is  of  great  importance,  especially  with  regard  to  its 
bacteriological  content.  Absolutely  pure  water,  as  Harrington 
points  out,  is  never  found  in  nature,  and  is  never  seen  except  in 
small  amounts  as  a  laboratory  curiosity.  All  water  holds  minerals 
and  gases  in  solution  and  usually  small  particles  in  suspension  {e.g., 
dust,  bacteria).  As  we  ordinarily  use  the  term  pure  water,  how- 
ever, we  mean  free  from  harmful  ingredients.  By  an  engineer  no 
water  containing  minerals  affecting  the  machinery  would  be  classed 
as  pure;  from  a  sanitary  standpoint  pollution  due  to  animal  or 
human  wastes  would  render  the  water  impure.  Rosenau's  classifi- 
cation of  water  as  (1)  good,  (8)  polluted,  or  (3)  infected  is  both 
simple  and  practical.  He  says :  "  A  good  water  may  be  defined  as 
one  of  good  sanitary  quality,  as  determined  by  physical  inspection, 
bacteriological  and  chemical  analyses,  a  sanitary  survey  of  the 
watershed,  and,  finally,  by  clinical  experience.  A  polluted  water 
is  one  containing  organic  waste  of  either  animal  or  vegetable  origin. 
A  polluted  water  is  a  suspicious  water.  An  infected  water  contains 
the  specific  micro-organisms  of  human  diseases." 

Most  waters  are  polluted  in  the  sense  just  defined.  Surface 
waters  could  hardly  escape  such  pollution.     Such  pollution  is  not 


94  HOME  AND  COMMUNITY  HYGIENE 

necessarily  injurious,  though  it  may — if  very  heavy — ^mean  a  high 
percentage  of  organic  matter  and  so  support  the  growth  of  unde- 
sira^ble  bacteria,  if  such  find  their  way  into  the  water  supply.  Well 
and  other  ground  waters  usually  contain  much  less  organic  matter, 
but  many  of  the  minerals  they  contain  result  from  the  decay  or 
breaking  down  of  plant  and  animal  substances — sometimes  termed 
the  "mineralization  of  organic  matter." 

Other  mineral  substances  affecting  the  potable  quality  of  water 
are  the  wastes  from  mines  and  manufacturing  establishments. 
These  rarely  affect  the  water  supply  except  in  closely  populated 
districts,  and  there  they  are  usually  a  part  of  the  whole  question  of 
sewage  disposal  (see  Chapter  YII,  p.  160). 

Water-borne  Diseases. — Disease  organisms  leave  the  body 
mainly  in  the  sputum,  nasal  discharges,  urine,  and  faeces.  Such 
human  wastes  infect  water  with  the  specific  organisms  of  disease 
{e.g.,  typhoid)  and  render  it  unsafe  for  human  consumption.  If 
the  contents  of  sewers,  drains,  swimming-pools,  and  privies  are  al- 
lowed to  enter  the  water  supply,  the  whole  question  of  sewage  dis- 
posal becomes  an  important  part  of  the  water  problem. 

Such  water-borne  diseases  may  cause  epidemics  of  typhoid, 
dysentery,  and  similar  diseases ;  even  when  this  is  not  so,  such  dis- 
eases often  form  an  undue  proportion  of  the  yearly  deaths,  and  the 
death  rate  is  higher  than  that  of  similar  neighborhoods  differing 
only  in  having  a  safe  water  supply.  For  example,  in  1905,  Phila- 
delphia with  a  population  of  1,417,003  had  724  deaths  from 
typhoid,  while  Camden,  on  the  opposite  side  of  the  Delaware  Eiver, 
with  a  population  of  87,000  had  but  15  typhoid  deaths.  In  other 
words,  Philadelphia,  taking  its  water  from  the  Schuylkill  River, 
with  but  sixteen  times  the  population  of  Camdei^  had  fifty  times 
the  typhoid  death  rate  of  Camden,  whose  water  at  that  time  came 
from  deep-bored  wells. 

This  effect  upon  the  typhoid  death  rate  is  also  shown  by  the 
following  table,  which  gives  the  deaths  per  100,000  for  several 
cities  in  about  the  same  latitude.  Note  particularly  the  differences 
between  Jersey  City  and  New  York,  cities  like  Camden  and  Phila- 
delphia so  close  together  that  the  difference  in  the  water  supply 
must  be  the  main  cause  of  the  difference  in  the  typhoid  rate;  con- 
sidering the  heavy  daily  migration  across  the  separating  rivers,  one 
wonders  how  much  greater  the  contrasts  really  are. 


WATER  95 

Rate  per  100.000 
City  (1896)  Source  Deaths 

Brooklyn    Wells  and  impounded  ^  water  15 

New  York  City Impounded  water  16 

Detroit   Detroit  River  20 

Providence   Pawtuxet  River  27 

Philadelphia    Delaware  and   Schuylkill  Rivers  34 

Cleveland   Lake  Erie  43 

Chicago    Lake  Michigan  46 

Pittsburgh Allegheny  River  6P 

Jersey  City   Passaic  and  Pequannock  Rivers  61.5 

A  large  number  of  epidemics  have  been  shown  to  be  water-borne. 

Eosenau  mentions  five  typhoid  epidemics  in  the  United  States 
in  which  each  outbreak  was  traced  to  a  single  individual.  One  was 
traced  to  a  man  who  contracted  typhoid  while  on  a  Christmas  visit. 
The  discharges  were  thrown  out  on  the  snowy  hillside  just  above  the 
town  reservoir,  and  three  weeks  after  the  spring  thaw  began,  the 
first  cases  occurred  in  the  town  below.  They  finally  totalled  one- 
sixth  of  the  total  population  of  the  town.  These  five  individuals 
are  credited  with  3929  cases  of  typhoid,  including  361  deaths. 

Relation  of  Water  to  General  Health. — In  various  cities — 
though  not  all — the  establishment  of  a  better  water  supply  has 
shown  not  only  a  decrease  in  water-borne  diseases  but  also  a  de- 
crease in  other  diseases,  notably  tuberculosis,  pneumonia,  and  other 
respiratory  diseases  which  are  not  commonly  considered  water- 
borne  (see  Chapter  XIX). 

This  decrease  ("the  Mills-Eeincke  phenomenon")  is  partly 
explained  by  some  as  due  to  the  purer  water  supplied ;  for  the  vital 
resistance  (G)  of  the  body  may  be  lowered  by  drinking  water 
charged  with  large  numbers  of  bacteria  even  though  they  are  not 
specifically  pathogenic.  Others  feel  this  phenomenon  is  merely  a 
coincidence;  that  any  community  spending  large  sums  on  improv- 
ing its  water  supply  is  also  sufficiently  alert  to  the  general  hygienic 
problems  to  improve  other  conditions  also,  e.g.,  housing  and  milk 
supply.  ^ 

Ice  in  Relation  to  Disease. — Single  cases  of  typhoid  and  a  few 

*  Impounded  is  a  term  applied  to  water  from  rivers,  watersheds,  etc., 
held  back  by  dams.     Such  water  forms  huge  basins  or  open  reservoirs. 

^ River  water  rates  vary  much  more  than  other  waters;  in  1906  Pitts- 
burgh's typhoid  rate  was  120! 


96  HOME  AND  COMMUNITY  HYGIENE 

small  epidemics  have  been  reported  as  traced  to  ice.  This  is  not 
surprising  when  one  recalls  how  ice  is  collected  and  treated.  Natural 
ice  is  cut  and  harvested  with  little  regard  for  ordinary  sanitary 
observances,  men  and  horses  working  on  its  surface  for  days  at  a 
time.  In  manufactured  ice,  if  made  in  closed  tanks,  the  water  is 
first  boiled  or  distilled  to  get  rid  of  sediment  and  air.  When  the 
artificial  ice  is  frozen  in  fiat  open  pans  (plate  ice)  part  of  the 
sediment  settles;  the  rest  of  it  and  the  air  are  extruded  in  the 
freezing  process,  and  it  is  not  necessary  to  boil  the  water  first  in 
order  to  get  clear  ice.  Plate  ice  is,  therefore,  not. safe  unless  a  re- 
liable water  supply  is  used,  or  unless  the  manufacturers  do  take  the 
extra  trouble  of  boiling  the  water  first. 

During  freezing  and  subsequent  storage  many  bacteria  are 
killed.  For  typhoid,  which  interests  us  most,  though  dysentery 
and  other  water  organisms  are  also  important,  the  following  re- 
sults are  given  by  different  workers. 

The  freezing  process   itself 50—  70  per  cent,  killed 

Storage  after  freezing,  1  week 50-  90  per  cent,  killed 

Storage  after  freezing,  2-4  weeks 90-  99  per  cent,  killed 

Storage  after  freezing,  3-6  months. ......  .99-100  per  cent,  killed 

While  these  figures  are  quite  comforting,  they  apply  only  to  the 
bacteria  frozen  with  the  ice.  Bacteria  in  wastes  falling  on  the  ice 
afterward,  or  coming  into  contact  with  ice  afterward — dirty  side- 
walks, manure — or  saliva-soiled  hands  of  drivers,  porters,  and 
waiters — or  bacteria  in  infected  water  temporarily  cooled  by  ice, 
are  not  necessarily  affected  in  number  or  virulence.  In  two  in- 
stances epidemics  have  been  traced  to  snow  in  or  on  which  typhoid 
discharges  lay  for  several  weeks,  and  with  the  spring  thraw  ran  into 
the  water  supply  affecting  a  large  percentage  of  the  consumers. 

It  is,  of  course,  difficult  to  trace  diseases  back  to  ice;  ice  is  as 
evanescent  as  the  "  snows  of  yesteryear."  Yet  the  above  indicates 
that  a  real  danger  may  be  avoided  by  using  only  long-stored  ice  or 
ice  made  either  from  boiled  or  a  chemically  treated  water.  Even 
tnen  ice  should  be  carefully  washed  to  remove  all  surface  contami- 
nations, making  sure  that  none  of  the  melting  exterior  is  retained 
for  use.  Ice  in  foods  is  doubtless  attended  with  some  risk,  and 
could  we  persuade  ourselves  to  forego  the  "clink  of  tlie  ice"  our 


WATER  97 

digestive  apparatus  would  also  be  spared  the  shock  and  inhibited 
periods  associated  with  such  chilling  temperatures. 

Methods  of  Testing  Water. — The  character  of  a  water  supply 
is  sometimes  indicated  by  color,  odor,  and  by  lack  of  clarity.  These 
are  far  from  satisfactory  tests,  however,  as  water  that  is  bacterio- 
logically  very  good  and  entirely  safe  may  have  fine  earthy  suspen- 
sions, a  decided  color  (from  soil  or  roots)  or  a  most  objectionable 
odor  (due  to  harmless  green  alg£e,  G).  And  water  passing  these 
physical  tests  may  contain  dangerous  disease  organisms.  We  need, 
therefore,  other  and  more  exact  ways  of  testing  drinking  water. 

This  is  sometimes  done  by  chemical  tests :  ( 1 )  for  the  total 
amount  of  organic  substance,  ordinarily  low  in  water;  (2)  for  sub- 
stances formed  by  undesirable  bacteria  in  polluted  water  (e.g., 
ammonia). 

Bacteriological  Tests. — There  are  also  two  ways  of  testing 
water  bacteriologically :  (1)  by  counting  the  bacteria  present  in  a 
definite  sized  sample  or  unit  of  water;  and  (2)  by  showing  that  a 
given  sample  has  in  it  certain  undesirable  or  injurious  organisms. 

In  the  first  way  the  bacteria  are  estimated  by  counting  the  num- 
ber of  colonies  that  develop  in  a  Petri  dish  containing  a  given 
amount  of  the  water  to  be  tested  (see  plate  count  in  Glossary). 

The  second  test,  that  a  given  sample  of  water  contains  unde- 
sirable or  dangerous  bacteria,  is  usually  made  by  adding  small 
amounts  of  the  sample  to  different  kinds  of  media,  selecting  usually 
the  media  in  which  most  bacteria  will  not  grow,  but  in  which  the 
bacteria  for  which  we  are  on  the  lookout  will  outgrow  all  others  or 
will  grow  in  characteristic  ways.  Using  such  media,  we  can  some- 
times show  that  typhoid  or  cholera  organisms  are  present. 

The  intestines  of  practically  all  domestic  animals  contain  an 
organism  known  as  Bacillus  (or  Bacterium)  coli.  B.  coli  is  not 
present  in  unpolluted  water.* 

■•Investigations  sliowed  B.  coli  in  but  2  of  58  wells  (and  in  but  5  of  21 
stagnant  pools ) .  If  this  organism  is  found  in  water,  it  is  taken  as  an 
evidence  of  pollution,  even  though  human  disease  organisms  are  not  dem- 
onstrated. Typhoid  organisms  could  hardly  be  found  in  water  without  the 
more  numerous  colon  bacteria.  Absence  of  the  colon  bacteria,  therefore, 
would  indicate  a  probable  freedom  from  typhoid  organisms.  Such  tests, 
called  presumptive  tests  ( G ) ,  are  given  more  weight  than  estimates  of  the 
numbf'i-  of  bacteria  present. 

7 


98  HOME  AND  COMMUNITY  HYGIENE 

It  is  impossible  to  give  any  satisfactory  figures  for  judging  of 
the  safety  of  water.  A  tiigh  count  indicates  only  that  a  large 
number  of  bacteria  are  present,  and  tells  us  nothing  of  the  kind — 
harmless  or  harmful. 

For  the  kinds  of  bacteria  present  we  have  to  rely  on  the  pre- 
sumptive tests  (G).  As  Park  puts  it:  "The  absence  of  colon 
bacilli  in  water  proves  its  harmlessness  so  far  as  bacteriology  can 
prove  it.  .  .  .  In  delicacy  the  colon  test  surpasses  chemical 
analysis;  in  constancy  and  definiteness  it  also  exceeds  the  quantita- 
tive bacterial  count."  A  large  number,  however,  indicates  one  of 
two  things:  (1)  heavy  and  recent  pollution,  as  by  sewage,  or  (2) 
a  large  amount  of  organic  material  which,  while  not  necessarily 
dangerous  (manured  fields),  is  objectionable  and  also  capable  of 
supporting  the  multiplication  of  bacteria.  Eeliable  authorities 
consider  100  to  200  bacteria  per  c.c.  (G)  the  limit  to  be  expected 
in  well  waters  not  receiving  surface  pollution ;  and  waters  contain- 
ing more  should  be  treated  to  reduce  the  number  to  at  least  100  per 
c.c.  before  they  are  used  for  drinking  pu^'^noses. 

Bacterial  Content  of  Various  Waters. — Ground  filtered 
waters,  such  as  wells,  and  quiet  waters,  such  as  lakes,  have  a  rather 
low  bacterial  content.  Eiver  water  varies  greatly,  mainly  because 
of  the  difl'erences  in  organic  wastes  draining  or  emptying  into  it 
{e.g.,  manured  fields,  city  sewers). 

The  various  types  of  water  (wells,  cisterns,  lakes,  rivers, 
springs)  differ  greatly  in  their  opportunities  for  pollution  and  in 
their  bacterial  content;  there  is  almost  an  equal  range  in  any  of 
these  groups.  To  illustrate,  well  water  is  usually  less  than  200  per 
c.c.  in  its  bacterial  count;  but  wells  may  have  thousands  per  c.c, 
and  the  death  rate  from  one  well  has  in  known  cases  been  greater 
than  that  of  all  the  other  water  used  by  the  rest  of  the  community ; 
one  London  well  had  a  record  of  over  700  eases  of  cholera. 

Suspicious  water  should  be  reported  to  the  proper  authorities, 
the  local  health  board  or  more  often  to  the  State  board.  Samples 
for  examination  should  be  taken  by  them — or  under  their  direction 
— as  the  origin  of  the  water  and  recent  history  (fioods,  etc.)  affect 
greatly  the  interpretation  of  the  laboratory  results.  Samples  should 
be  taken  when  they  can  be  examined  promptly,  as  their  numbers 
may  increase  or  decrease  on  standing  (standing  raised  a  count  of 


WATER  99 

7  per  c.c.  to  485,000 ;  in  another  case  the  count  fell  from  535,000 
to  54,500). 

The  various  types  of  water  differ  in  their  physical  and  chemical 
qualities  as  well  as  in  their  bacteriological  content.  The  most  im- 
portant of  these  relations  are  discussed  in  the  following  paragraphs. 

Rain  and  Cistern  Water. — Small  amounts  of  rain  (or  snow) 
are  sometimes  collected  on  roofs,  or  specially  constructed  areas,  and 
stored  for  use  {e.g.,  cisterns).  Such  water  has  in  it  certain  chemi- 
cal impurities  absorbed  from  the  air,  e.g.,  carbon  dioxide.  Be- 
sides, may  be  found  such  mineral  substances  as  common  salt  (from 
ocean  spray),  nitric  acid  (from  factories),  and  sulphuric  acid 
(from  burning  coal). 

Such  substances  lead  to  the  changes  observed  in  water  held  in 
metal  tanks,  making  an  inert  lining^  {^-Q-,  asphaltum)  advisable 
for  the  tanks,  cisterns,  and  delivery  pipes.  The  use  of  lead  for 
tanks  is  dangerous;  and  even  for  delivery  pipes  it  is  very  ques- 
tionable, although  some  water  companies  still  insist  that  a  lead 
pipe  should  be  used  between  the  main  service  pipes  and  the  water 
meter.  (This  is  required  because  of  the  effect  of  disintegrating 
iron  on  the  mechanism  of  the  meter.)  When  the  house  is  a  long 
way  from  the  street  main,  the  consumer  may  suffer  from  lead 
poisoning. 

Water  and  snow  wash  out  of  the  air  suspended  particles  also; 
in  fact,  the  formation  centre  of  a  droplet  of  water,  a  snowflake,  or  a 
hailstone  is  usually  composed  of  particles  of  dust  or  bacteria.  The 
bacteria  are  rarely  numerous  enough  to  be  a  menace ;  even  if  of  the 
types  that  will  multiply  in  rainwater  tanks,  they  are  usually  not 
of  the  kind  that  cause  disease  in  man,  and  the  slight  amount  of 
organic  material  in  clean  rainwater  would  not  aid  in  rapid  multi- 
plication of  such  organisms.  If  the  collection  area  is  not  clean  {e.g., 
birds  roosting  on  the  edge  of  the  roof  or  nesting  in  the  gutters), 
the  water  may  be  highly  polluted  with  organic  matter.  The  or- 
ganisms from  such  sources  are  not  considered  injurious  to  man, 

^Cement  or  bricks  make  a  better  cistern  lining  than  mortar;  tlie  lime 
in  the  latter  tends  to  make  the  water  hard.  Lead  is  corroded  readily  by 
free  acids  in  the  water;  oxygen  with  water  has  also  great  corrosive  power. 
Iron  is,  affected  by  such  substances  as  nitrates,  organic  and  mineral  acids; 
zinc  is  also  easily  corroded,  and  is  charged  with  causing  chronic  and 
obstinate  cases  of  constipation. 


100 


HOME  AND  COMMUNITY  HYGIENE 


but  such  water  is  not  clean  water,  and  besides  being  unattractive, 
often,  in  color  and  taste  as  well  as  association,  it  may,  because  of  its 
organic  content,  afford  nutrient  material  for  other  harmful  organ- 
isms that  may  later  enter  the  cistern  through  imperfect  covers, 
pump  floors,  or  broken  side  walls  (Fig.  29).  A  still  greater  danger 
is  found  in  open  cisterns  (or  other  tanks,  such  as  roof  tanks)  which 
allow  mosquitoes  to  breed  in  the  water.  Malaria  and  yellow 
fever  are  both  carried  by  mosquitoes,  which  breed  rapidly  under 
such  conditions,  and  many  hotels  and  private  houses  thus  supply 


FiQ.  29. — Two  wells,  both  of  loose-stone  construction.  One  has  a  double  floor  and  a 
cement  rim  all  around  the  exposed  part  of  the  wall  spreading  out  2  to  3  feet  around  the  well. 
What  advantages  does  it  possess  over  the  one  on  the  right? 

themselves  as  well  as  their  neighbors  with  a  constant  succession  of 
mosquitoes. 

Surface  and  Soil  Water. — Most  of  the  water  that  falls  to  the 
surface  of  the  earth  is  not  caught  in  cisterns.  It  travels  appre- 
ciable distances  as  surface  water  or  soaks  into  the  ground.  This 
ground  water  which  penetrates  the  earth's  surface  ma}^  apjDear  more 
or  less  promptly  as  springs  (on  hillsides,  in  the  beds  of  other 
streams)  or  join  other  surface  water  collected  in  streams,  rivers, 
lakes,  oceans.  Such  bodies  of  water  contain  bacteria  and  organic 
matter  as  well  as  inorganic  material  characteristic  of  the  area  over 
(or  through)  which  they  have  passed. 

The  acids  mentioned  earlier  as  acquired  from  the  air,  including 
carbonic  acid,  derived  from  the  CO2  of  the  air  and  soil,  may  help 


WATER  101 

dissolve  minerals  in  the  soil,  and  the  ''soft"  rainwater  (contain- 
ing no  alkaline  earths)  may  become  "  hard."  ^  Hard  water  is  some- 
times injurious  to  the  skin  of  workers  who  must  keep  their  hands 
in  it  for  long  periods;  it  makes  such  processes  as  dish- washing 
more  expensive,  as  it  takes  more  soap  to  produce  a  satisfactory 
cleansing  lather  (four  to  eight  times  as  much).  Certain  vegetables 
are  said  to  be  affected  by  the  hardness  of  the  water  in  which  they 
are  cooked,  becoming  thereby  hardened  and  less  digestible.  In  fac- 
tories, hard  water  may  :^orm  deposits  inside  boilers,  etc.,  injuring 
them  or  demanding  expensive  removal  processes. 

Other  minerals  may  be  found,  some  of  which  give  to  certain 
waters  their  characteristic  tastes  or  therapeutic  reputations;  some- 
times peculiar  or  objectionable  tastes  are  very  prominent;  there  is, 
however,  little  evidence  that  any  waters  that  people  would  drink 
contain  sufficient  amounts  of  any  harmful  mineral  to  be  injurious.'^ 
It  is,  however,  true  that  changes  from  hard  to  soft  water,  or  from 
soft  to  hard,  may  cause  digestive  disturbances,  and  constipation  or 
diarrhoea. 

The  surface  water  which  finally  collects  in  streams,  lakes,  etc., 
is,  as  already  stated,  characterized  by  bacterial  and  other  organic 
matter  from  the  surfaces  covered  or  drained  (decaying  plants  and 
animals,  manured  fields,  the  accumulations  of  private  or  community 
sewers).  Bacteria  in  such  water  disappear  rather  rapidly,  due  to 
such  natural  agents  as  dilution,  oxygen  and  sunlight. 


'Hardness  depends  mainly  on  the  amounts  of  magnesium  and  calcium 
salts  in  solution.  The  "hard"  elements  make  new  combinations  with  the 
soap  and  prevent  the  formation  of  a  lather  until  they  have  been  satisfied. 
Heating  expels  CO,  and  so  may  help  by  indirectly  causing  precipitation 
of  substances  that  otherwise  make  the  water  hard.  The  addition  of  lime 
when  the  hardness  is  due  to  chalk  or  magnesium  is  an  economical  way  of 
removing  hardness  in  such,  waters,  as  a  "few  cents'  worth  of  lime  will  re- 
move hardness  demanding  many  dollars'  worth  of  soap";  limewater  addi- 
tions, however,  do  not  reduce  hardness  caused  by  certain  other  substances. 
Sodium  compounds  are  often  helpfully  employed  in  certain  types  of  water. 
Such  variations  make  a  particular  brand  of  hard  water  soap  very  valuable 
in  some  communities  and  quite  useless  in  other  localities. 

'  There  is  probably  no  foundation  for  the  belief  that  gallstones  are 
produced  by  certain  types  of  hard  water ;  the  use  of  certain  wells  in  Europe 
to  produce  goitre  and  so  escape  compulsory  military  service  is  probably 
equally  mythical;  the  endemic  character  of  goitre  is  still  not  completely 
explained,  but  it  is  most  probable  that  the  explanation  of  its  endemic 
character  is  not  directly  a  question  of  hardness  of  the  water. 


102  HOME  AND  COMMUNITY  HYGIENE 

The  rain  or  snow  water  which  passes  into  the  soil  percolates 
rapidly  through  sandy  or  porous  soils,  slowly  through  clay  soils,  and 
finally  reaches  the  level  of  free  water  (ground  water)  found  deep 
in  all  soils.  In  some  soils  free-flowing  underground  streams  may  be 
found  far  underground;  e.g.,  in  limestone  regions  where  CO2  ab- 
sorbed from  the  soil  forms  carbonic  acid  which  dissolves  the  lime- 
stone rock;  or  similar  channels  may  be  worn  in  a  sandy  soil  by 
accumulated  water  which  cannot  penetrate  the  tightly-packed  clay 
layer  just  below  it.  Even  where  there  are  no  free  flowing  under- 
ground channels,  there  is  a  rather  constant  movement  of  the  ground 
water  in  all  soils,  following  the  general  slant  of  the  water-holding 
layers.  This  explains  why  a  well  may  cut  ofl  the  spring  supply 
farther  down  the  hillside;  and  why  wells  near  salt  water  (seashore, 
salt  lakes)  may  be  fresh,  not  salt. 

Bacteria  in  Deep-ground  Water. — Deep-ground  water  is 
comparatively  free  from  bacteria.  Most  of  the  soil  bacteria  are  in 
the  uppermost  part  of  the  soil  in  a  layer  but  four  to  six  inches  deep. 
Samples  of  soil  taken  four  to  five  feet  below  the  surface  contain  very 
few  bacteria.  Practical  aj^plication  is  made  of  this  fact  when  decid- 
ing the  depth  of  the  earth  or  sand  filters  used  for  our  water  sup- 
plies ;  they  are  commonly  eight  to  ten  feet  deep,  insuring  thereby  a 
margin  of  safety.  Wells  and  springs  that  are  supplied  by  deep- 
ground  veins  have,  therefore,  a  low  bacterial  count,  less  than  100 
to  a  cubic  centimetre,  usually.  Higher  counts  indicate  that  surface 
water  is  washing  into  the  well  (Fig.  29),  or  that  organic  material 
has  found  access  in  some  other  way,  e.g.,  cesspools  (Fig.  30).  The 
bacteria  that  cause  human  diseases  do  not  ordinarily  live  long  in 
soil,  and  would,  therefore,  be  but  rarely  represented  in  the  deeper 
soil  waters.  Cemeteries  are  not  ordinarily  considered  a  menace. 
Water  supplies  are  not  collected  from  such  areas  directly,  and  the 
filtering  power  of  the  soil  prevents  passage  of  pathogenic  bacteria 
to  the  deeper  soil  waters. 

Deep  Wells. — Artesian  or  deep  bored  wells  take  their  supply 
from  great  depths ;  often  sixty  to  one  hundred  feet,  and  not  un- 
commonly a  few  hundred  feet  down.  Such  water  usually  contains 
but  a  small  number  of  bacteria.  If  the  bacterial  count  is  high,  or 
the  water  changes  quickly  in  amount  or  appearance  (with  dry 
weather  or  after  rain  .storms),  the  water  layer  that  has  been  tapped 
lies  near  the  surface  of  the  ground,  and  somewhere  surface  bacteria 


WATER 


103 


are  doubtless  entering  the  well.  Normally,  artesian  tube  or  bored 
wells  deliver  safe  water.  It  is  a  common  practice  to  bore  down  until 
a  deep  sandstone  layer  has  been  passed.  Xext  is  usually  an  impervi- 
ous layer,  such  as  clay,  and  the  ground  water  which  filters  through 
the  upper  soil  layers  and  the  deep  sandstone  layer  (which,  strange 
to  say.  is  almost  as  porous  to  water  as  sand  itself)  collects  on  top 
of  the  impervious  clay  layer. 

The  slope  of  these  underground  layers,  and  the  proximity  of 
other  wells  tapping  the  -same  water  layer,  limits  the  amount  of  water 
any  well  can  furnish.    A  large  city  using  only  artesian  water  re- 


Cessf 


Fig.  30. — Note  that  the  well  on  the  left  might  be  polluted  by  the  cesspool  apparently 
down  the  slope  and  also  by  material  from  the  cesspool  on  the  right,  while  the  well  on  the 
right  would  escape  pollution. 

cently  had  to  add  a  large  surface  or  watershed  area  to  its  water 
system;  the  wells  already  in  use  were  delivering  all  that  the  water- 
bearing layers  could  yield. 

In  every  community  there  are  those  who  object  to  the  increasing 
cost  of  the  water  supply,  contending  that  they  '^  always  have  "  used 
unfiltered  water — or  untreated  water,  as  the  case  may  be — and  that 
their  present  unbroken  record  of  health  and  longevity  is  evidence 
that  what  always  lias  been  is  sufficient.  These  "  always  have's  "  are 
little  moved  when  one  patiently  explains  that  the  pollution  is  much 
greater  now  than  formerly,  and  that  we  can  no  longer  rely  wholly 
upon  such  natural  aids  as  sunlight,  oxygen,  or  storage  periods  to 
destroy  the  bacteria,  or  upon  dilution  to  lessen  our  chances  of  infec- 
tion by  them.  As  some  one  recently  pointed  out,  the  proper  way  to 
judge  of  unsanitary  conditions  is  not  by  the  healthy  survivors  but 
by  the  dead  and  fallen,  by  the  illnesses  and  deaths  of  the  rest  of 
the  community. 


104  HOME  AND  COMMUNITY  HYGIENE 

Purification  of  Water  by  Natural  Agents. — Sewage-polluted 
streams  are  constantly  having  fresh  and  relatively  unpolluted  water 
added  to  them.  Oxygen  and  sunlight  are  less  important  agents  in 
reducing  the  bacterial  count  of  water  than  formerly  believed.  A 
certain  amount  of  oxygen  is  always  found  in  unpolluted  water  (35 
per  cent,  of  the  contained  air),  less  m  polluted  water  (p.  152)  even 
though  wind-blown  waters  have  their  air  (and  oxygen)  content 
constantly  renewed.  Sunlight's  disinfecting  action — both  because  of 
the  effect  of  the  chemical  rays  at  the  blue  end  of  the  spectrum  and 
because  of  the  power  of  sunlight  to  form  H2O2  and  thus  liberate 
free  oxygen — is  not  felt  at  any  considerable  depth.  In  the  case  of 
rivers,  although  dangerous  organisms  emptied  into  the  river  by  one 
town  may  be  so  reduced  in  numbers  or  virulence  that  towns  twenty 
miles  down  the  river  escape  infection  when  using  such  water  for 
drinking  purposes,  even  when  it  is  very  incompletely  filtered,  yet 
few  reliable  sanitary  experts  would  recommend  drinking  such  water, 
even  after  filtering,  unless  it  were  also  chemically  disinfected;  the 
risks  are  too  great.  The  marked  decreases  in  bacteria  counts  due  to 
these  natural  agents  reported  by  many  investigators  (for  example, 
in  a  flow  of  ten  miles  a  count  of  48,000  per  c.c.  fell  to  200  per  c.c.) 
are  in  large  part  due  to  dilution. 

The  Mississippi  is  often  described  as  one  of  the  best  illustrations 
of  the  effects  of  these  natural  aids,  for  at  its  mouth,  after  having 
received  for  3000  miles  polluting  material  from  all  of  the  United 
States  which  lies  between  the  Eocky  and  Appalachian  Mountains, 
it  is  found  to  be  comparatively  free  from  intestinal  bacteria. 

Such  statements,  however,  as  that  water  "  purifies  itself  every 
two  hundred  feet,"  or  even  every  ten  miles,  are  wholly  without 
foundation,  and  should  be  emphatically  contradicted.  There  are 
many  unfortunate  illustrations  which  flatly  contradict  such  state- 
ments; for  example,  the  typhoid  epidemics  at  Lowell  and  Law- 
rence, or  the  typhoid  death  rate  of  Niagara  Falls.  An  epidemic  in 
Lowell,  which  discharged  its  sewage  into  the  Merrimac,  was  fol- 
lowed by  an  epidemic  at  Ijawrence,  nine  miles  further  down  the 
river;  Lawrence  used  the  unfiltered  river  water  for  drinking  pur- 
poses. This  sequence  of  epidemics  was  repeated  in  two  successive 
years,  until  Lawrence  constructed  a  filter  plant  to  filter  the  river 
water.  Niagara  Falls,  sixteen  miles  below  Buffalo,  receives  Buf- 
falo's sewage  in  a  few  hours,  and,  therefore,  before  the  institution  of 


WATER  105 

filters  and  chemical  treatment  had  the  highest  typhoid  rate  in  the 
United  States,  133  per  100,000. 

Epidemics  of  typhoid  have  been  traced  to  such  conditions,  even 
after  years  of  comparative  immunity;  differences  in  water  levels 
and  the  corresponding  per  cent,  of  pollution  may  at  any  time  cause 
serious  loss  of  life.  The  inadvisability  of  risking  such  chances  of 
wholesale  infection  is  evident;  and  no  self-respecting  community 
ought  to  submit  to  pollution  of  its  water  supply  by  up-river  towns ; 
still  less  should  it  discharge  its  own  untreated  sewage  in  a  way  to 
menace  its  neighbors  (see  Sewage  Disposal,  p.  152).  A  lake-town 
may  similarly  pollute  its  own  water  supply,  as  well  as  that  of 
neighborhood  towns. 

Sedimentation  and  Storage. — Sedimentation  is  another 
method  of  improving  the  water  supply,  and  occurs  in  conjunction 
with  the  natural  agents  previously  described.  In  practice,  sedi- 
mentation and  storage  are  so  commonly  combined  in  our  efforts  to 
improve  the  quality  of  water,  that  it  seems  simpler  to  discuss  sedi- 
mentation with  storage.  It  is  well  known  that  rapidly  moving 
streams  are  usually  muddier  than  slow  flowing  ones ;  that  lake  water 
is  clearer  than  river  water.  Small  as  bacteria  are,  they  are  rela- 
tively heavier  than  water,  and  unless  buoyed  up  by  water  currents, 
they  tend  to  sediment  out  of  the  water. 

Since  water  itself  is  not  usually  rich  in  organic  material,  bac- 
teria do  not  multiply  rapidly  in  it  but  tend  to  die  off.  (They  are 
constantly  being  replaced  by  surface  washings,  etc.,  and,  so,  brooks 
and  rivers  are  never  free  from  bacteria.)  Water  for  city  use, 
therefore,  is  often  held  weeks  or  even  months  in  large  reservoirs; 
during  that  time  the  bacteria  sediment  out  (remaining  behind 
when  the  water  is  drawn  off),  and  many  bacteria  die  for  lack  of 
food.  Freezing  generally  hastens  the  death  of  bacteria;  the  pene- 
trating sunlight  aids  also,  though  in  open  reservoirs  sunlight  may 
favor  the  growth  of  various  green  water  plants  (mainly  algge)  and 
lead  to  the  accumulation  of  undesirable  gases  or  odors.  (Aeration 
by  forcing  large  amounts  of  air  through  the  water  as  it  leaves  the 
reservoir,  is  a  common  method  of  removing  such  accumulations.) 
In  small  communities  where  thorough  filtration  entails  too  great  an 
expenditure  of  money,  good  results  are  obtained  by  storage,  espe- 
cially where  two  or  three  reservoirs  are  used  in  sequence,  thus  in- 
suring a  long  storage  period.     Boston  boasts  a  thirty-day  storage 


106 


HOME  AND  COMMUNITY  HYGIENE 


period;  a  still  longer  period,  thirty-five  days  at  least,  is  given  the 
Catskill  water  supplied  to  New  York  City. 

1  Filtration. — Our  discussion  of  the  bacteria  in  soil  waters  has 
shown  that  an  important  "  natural "  method  of  improving  the  water 
supply  is  filtration.  Normalh',  the  soil  holds  back  most  of  the  bac- 
teria in  the  water  which  passes  through  it.  But  no  one  would 
expect  soft,  water-soaked  ground,  or  soil  saturated  by  the  manure 


Fig.  31. — Diagram  of  a  section  of  a  covered  sand  filter.  V.  C.  is  a  ventilation  cap.  C.  is  a 
collecting  main  collecting  water  from  the  smaller,  loosely- jointed  pipes  in  the  gravel  area. 
(Sand  about  four  feet  depth.) 

accumulations  of  years,  to  be  effective  filters.  In  specially  con- 
structed sand  filters  (Fig.  31),  through  which  millions  of  gallons 
of  water  pass  daily,  the  top  may  become  covered  with  a  gelatinous 
mass  of  organic  material  *  which  for  a  time  helps  filter  the  water, 
but,  increasins:  in  thickness,  finally  delays  the  passage  of  water. 


*  This  film  increases  the  efficiency  of  the  filter  at  first.  Its  formation 
is  sometimes  assured  by  usino-  a  coagulant  in  the  water  (e.  g.,  aluminum 
sulphate).    This  helps  to  clarify  the  water  as  well. 


WATER  107 

Such  sand  filters  need  to  have  the  top  layer  scraped  off  about  once  a 
month,  and  should  be  dried  and  aerated  between  the  filtering 
periods.  Two  or  more  filters  usied  in  sequence  make  proper  clean- 
ing and  aeration  possible.  (P.  156.  For  mechanical  filtration  siee 
p.  114,  problem  10.) 

House  Filters. — Wonderful  as  some  of  the  stone  and  porcelain 
filters  are  at  their  best  (removing  99  to  100  per  cent,  of  the  bac- 
teria) there  are  none  adapted  to  household  uses  for  one  or  more  of 
the  following  reasons:  .(1)  Because  they  hold  large  amounts  of  un- 
filtered  water  in  contact  with  the  held-back  organisms  at  warm  room 
temperatures;  (2)  because  organisms  grow  through  the  filtering 
material  and  pass  out  with  the  filtered  water;  (3)  because  they 
need  to  be  cleaned  (scrubbed  and  boiled)  frequently;  or  (4)  be- 
cause they  deliver  water  so  slowly  that  servants  and  others  using 
them  will  not  spend  the  requisite  time  in  collecting  water,  and 
either  loosen  the  joints  or  add  other  water  to  the  filtered  supply. 

.House  filters  should  not  be  made  of  animal  charcoal^  as  bac- 
teria may  grow  in  it.  Charcoal  has  too  high  a  place  in  popular 
estimation  due  to  its  affinity  for  organic  matter,  which  clarifies  the 
water.  The  improvement  in  appearance  has,  unfortunately,  no  rela- 
tion to  the  bacterial  content. 

Self-cleaning  house  filters  are  not  reliable.  Some  may  be  used 
for  two  or  three  weeks  without  cleaning  (scrubbing,  and  boiling), 
but  others  are  good  for  but  two  or  three  days.  'No  self-cleaning  or 
reversible  filter  ought  to  be  used  just  after  reversing  the  flow,  as 
bhe  pent-up  bacteria  and  sediment  are  discharged  when  the  flow  is 
reversed.  Like  all  other  filters,  they  may  not  become  fully  efficient 
until  a  film  of  sediment  and  bacteria  has  been  deposited  on  the 
filtering  substance. 

Park  says :  '^  Water  which  requires  private  filtering  should  not 
be  supplied  for  drinking  purposes.    Unhappily  it  often  is." 

A  simple  and  safe  method,  if  the  water  supply  furnished  by  the 
city  is  not  clear  or  not  bacteriologically  safe,  would  be  to  boil  the 
water  to  kill  pathogenic  bacteria  and  then  filter  it  through  some 
type  of  cotton-pad  filters  to  remove  sediment,  etc.  There  are  at 
least  three  types  on  the  market  which  can  be  fitted  on  water  coolers, 
etc.,  costing  $0.50  to  $1.00  each  (with  pads  at  one  to  three  cents). 
These  have  a  distinct  advantage  in  that  they  are  easily  cleaned;  the 
cotton  pads  should  be  replaced  daily. 


108  HOME  AND  COMMUNITY  HYGIENE 

Heat. — Probably  the  simplest  method  of  rendering  water  safe 
is  boiling.  A  temperature  of  80°  C.  (176°  F.)  for  one  minute  kills 
practically  all  the  organisms  pathogenic  to  man.  Boiling  ^  (100°  C. 
or  212°  F.),  therefore,  makes  doubly  sure,  and  does  away  with  the 
need  of  a  thermometer.  Heat  is  not  used  on  a  large  scale  in  im- 
proving public  water  supplies,  though  Jordan  has  recommended 
subjection  to  a  lower  pasteurizing  temperature  (60°  C.)  for  a 
longer  period  of  time.  In  many  cases  it  would  seem  possible  to 
devise  a  scheme,  especially  where  water  towers  are  used,  for  pass- 
ing the  outflow  from  the  reservoirs  slowly  through  a  heated  chamber 
or  area  (chimneys,  etc.),  and  thus  rendering  the  water  safe.  In 
properly  constructed  plants,  heat  could  act  continuously ;  this  would 
be  better  than  the  periodic  addition  of  disinfectants,  and  would  not 
have  the  risk  attached  of  water  stored  too  short  a  time,  or  incom- 
pletely filtered,  or  it  might  well  be  made  a  permanent  addition  to 
other  measures  for  improving  the  water  supply. 

Purification  by  Chemicals. — Sometimes  bacteria  in  water  are 
killed  by  adding  chemicals.  Copper  sulphate,  popular  some  years 
ago,  has  been  replaced  by  certain  calcium  or  sodium  compounds 
known  as  hypochlorites,  and  often  popularly  called  "  bleach "  or 
"  chlorides. ^^  (They  are  not  chlorides,  but  differ  materially  in  their 
composition;  for  example,  calcium  chloride  is  CaClj,  and  calcium 
hypochlorite  is  CaOaClj.)  The  hypochlorites  are  much  stronger 
disinfectants,  due  probably  to  the  fact  that  they  are  much  less  stable 
compounds,  liberating  both  oxygen  and  chlorine,  and  both  of  these 
gases  are  strong  disinfecting  agents;  most  authorities  agree  that 
the  main  value  lies  in  the  oxygen  liberated.  The  chlorine  liberated 
is  mainly  valuable  because  it  causes  chemical  changes  which  liberate 
more  oxygen.  Hypochlorites  are  added  to  the  water  in  coarse  pow- 
der form,  and  are  effective  in  very  small  amounts,  one  to  four  parts 
of  powder  to  a  million  parts  of  water,  depending  upon  the  condi- 
tion of  the  water,  e.g.,  organic  matter  or  bacteria  present.  In  ordi- 
nary water  the  bacteria  are  reduced  99  per  cent,  by  such  treatment. 

°  Directions  usually  say  boil  ten  minutes.  This  is  to  insure  its  really 
reaching  a  killing  temperature.  Many  people,  strange  to  say,  do  not  know 
when  water  is  really  boiling.  The  flat  taste  due  mainly  to  the  lack  of 
air  can  be  removed  bv  beating  the  water  with  an  egg  beater  or  by  pouring 
the  water  back  and  forth  from  vessel  to  vessel.  (Such  vessels  should  not 
contain  or  be  wet  with  unboiled  water — or  the  value  of  the  whole  process 
is  lost.) 


WATER  109 

Introduced  but  ten  years  ago  in  treating  water  receiving  the  Chicago 
stock-yard  discharges,  the  hypochlorites  have  grown  rapidly  in  favor 
and  are  still  deservedly  popular  for  treating  water  supplies  and 
swimming  pools  (see  Appendix). 

"  Bleach ''  deteriorates  rapidly  when  exposed  to  the  air ;  allow- 
ance must  be  made  for  this  in  estimating  the  amount  to  be  used. 
These  amounts  are  far  below  the  amounts  that  can  be  detected  by 
taste.  In  reservoirs  and  swimming  pools  with  a  continuous  intake, 
the  ''  bleach  "  must  be  added  at  intervals  sufficiently  spaced  to  in- 
sure sufficient  action.  Storage  reservoirs,  of  course,  need  to  be 
treated  but  once  with  each  filling. 

Another  oxygen  treatment  strongly  advocated  from  time  to  time 
is  the  form  of  oxygen  known  as  ozone  (O3).  Ozone  has  a  strong 
bactericidal  value  (99  per  cent.),  but  its  value  is  affected  by  the 
fact  that  organic  matter  unites  with  it,  and  that  it  may  give  un- 
pleasant tastes,  or  lead  to  digestive  disturbances.  The  necessary 
electrical  apparatus  is  complicated  and  far  from  "  fool-proof  " ;  an- 
other disadvantage  is  that  unused  ozone  corrodes  the  water  pipes. 
It  cannot  compete  with  the  later  and  deservedly  more  popular  ad- 
dition of  chlorine  and  hypochlorites.   ( See  Appendix  for  home  uses. ) 

Liquid  chlorine,  more  recently  introduced  in  treating  large 
quantities  of  water,  is  just  as  effective  as  "  bleach,"  and  acts  in 
much  the  same  manner.  It  may  be  secured  in  small  tanks  for 
private  or  institutional  use,  and  it  has  some  advantages  over 
"bleach";  it  does  not  deteriorate,  objectionable  tastes  or  odors  are 
less  common,  it  is  simpler  and  often  cheaper  to  set  up  and  operate. 
Our  largest  cities  are  using  either  chlorine  or  hypochlorites  with 
satisfactory  results :  among  them  are  New  York  City,  Buffalo,  Balti- 
more, Chicago,  and  Philadelphia. 

One  of  the  new  methods  which  promises  well  is  the  using  of  the 
strong  chemical  light  rays — the  ultra-violet  rays.  With  the  right 
kinds  of  apparatus  {e.g.,  quartz  globes  instead  of  glass  globes  for 
the  "lamps,"  as  glass  limits  the  passage  of  the  rays)  very  efficient 
action  is  secured:  in  clear  water  most  of  the  bacteria  are  killed  in 
one  minute.  One  or  more  lamps  are  placed  in  small  tanks  or  out- 
flowing chambers,  and  50  to  200  gallons  per  hour  may  be  treated 
by  each  lamp. 

The  following  table,  taken  from  a  report  of  water  supplies  in 


no 


HOME  AND  COMMUNITY  HYGIENE 


New  York  State,  illustrates  the  beneficial  effects  of  some  of  these 
ways  of  treating  water : 


Typhoid 

Typhoid 

rate  per 

rate  per 

100,000 

100,000 

population 

population 

City 

Present  water  supply 

for  period 
before  the 
change 
ranging 
from  4  to 
23  years 

Change 

since 
change 
through 
1915 
(3-15 
years) 

Albany 

Hudson  River .... 

89 

Slow  sand  filters; 
hypochlorite 

20 

Binghamton 

Susquehanna  River 

50 

Mechanical  filters 

12 

Cohoes 

Mohawk  River .  . . 

89 

Mechanical  filter; 
hypochlorite 

28 

Ithaca 

Six-mile  Creek. . .  . 

78 

Mechanical  filter; 
hypochlorite 

19 

Lockport 

Niagara  River .... 

["57 

Changed  from  Erie 

33 

Canal  to  Niagara 

133 

River 

Liquid  chlorine . .  . 

8 

Niagara  Falls  — 

Niagara  River 

128 

Mechanical  filters; 
hypochlorites 

29 

Ogdensburg 

St.  Lawrence  River 

50 

Slow  sand  filters 

16 

Schenectady 

Large  wells  inter- 
cepting   ground 
water     flow     to 
river 

86 

Discontinued  use 
of     M  ohawk 
River 

11 

Troy 

Surface    streams 
and  lakes 

56 

Discontinued 
Hudson      River 

24 

part  of  supply 

Amounts  Necessary, — The  large  amounts  of  water  consumed 
in  our  larger  cities — one  hundred  to  two  hundred  and  fifty  gallons 
daily  per  person — ^makes  it  quite  difficult  to  supply  such  large 
amounts  of  high  quality  water  without  great  expense  to  the  com- 
munity concerned.  The  figures  for  most  European  towns  and  cities 
are  well  under  seventy  gallons  per  person,  usually  less  than  forty  or 
fifty  gallons ;  even  London  has  a  per  capita  consumption  of  only  forty 
gallons  per  person.  The  differences  in  water  consumption  do  not 
always  indicate  different  standards  of  cleanliness.  They  are  more 
often  due  to  the  following  causes:  (1)  Large  consumption  by  manu- 


WATER  lit 

facturing  plants;  (2)  a  wide  difference  in  the  amounts  used  for 
community  measures,  sucii  as  street-cleaning,  disposal  of  sewage  by 
water  carriage,  fire-j^rotection,  and  public  parks;  (3)  large  estates 
with  well-kept  lawns,  etc.,  may  swell  the  per  capita  rating  when 
compared  with  the  strictly  household  uses  in  many  towns  and  cities ; 
(4)  leakage  in  the  water  mains  due  to  leaking  joints,  defective 
(hydrolyzed)  pipes  (10  to  50  per  cent,  loss) ;  (5)  the  difference  due 
to  the  methods  of  sewage  disposal :  by  private  privies  or  cesspools 
or  by  a  more  extended  water-carriage  system,  including  street  as 
well  as  house  sewers  with  final  disposal  at  a  distant  point ;  ( 6 )  loss 
in  the  houses,  factories,  etc.,  due  to  leakage  or  carelessness.  This 
last  accounts  for  much  of  the  difference.  Dripping  faucets  and  im- 
perfect valves  {e.g.,  in  boilers  and  toilet  tanks)  account  for  much 
of  it;  and  constant  running  to  prevent  freezing  often  balances  the 
increased  summer  consumption  (bathing,  grass-sprinkling,  etc.). 
These,  and  other  less  excusable  forms  of  carelessness  are  common 
where  the  cost  of  the  water  is  not  charged  to  the  consumer  on  the 
basis  of  the  amount  ^°  consumed.  Metering  the  water  supply  com- 
monly results  in  a  50  per  cent,  reduction  in  any  community.  While 
it  is  difficult  to  allow  fairly  for  the  commercial  demands,  water 
company  records  for  metered  areas  for  many  small  towns  show  but 
a  40  to  50  gallon  per  capita  consumption,  even  when  the  watering 
of  lawns,  gardens,  etc.,  is  included;  it  seems  fair  to  consider 
80  to  100  gallons  per  capita  sufficient  for  the  average  town,  includ- 
ing in  that  amount  also  the  civic  water  supply.  More  than  that  in- 
creases the  living  expenses  unduly  (whether  paid  directly  by  the 
consumer,  or  indirectly  in  taxes),  and  does  not  necessarily  improve 
the  sanitary  conditions  of  the  community  or  the  health  of  the  indi- 
vidual ;  and  the  saving  to  the  community  might  well  go  toward  other 
hygienic  improvements  not  so  generally  conceded  by  the  taxpayer 
as  is  the  demand  for  good  water. 

Cost  is  an  important  consideration,  but  the  amount  of  water  is 

^°  Less  satisfactory  is  the  practice  of  charging  according  to  the  number 
of  outlets  per  house. 


112  HOME  AND  COMMUNITY  HYGIENE 

itself  limited.  The  rainfall  (collected  in  rivers  and  lakes)  and 
ground  water  (springs  and  wells)  are  often  insufficient  to  meet  the 
amount  demanded  by  a  community. 

Even  where  the  amount  is  sufficient  {e.g.,  rivers)  its  condition 
(commonly  heavily  polluted  with  sewage)  and  the  large  amount 
needed  (street  flushing,  fire  prevention,  park  uses,  and  irrigation) 
often  make  water  unduly  expensive. 

It  has  been  suggested  that  a  double  water  supply  might  solve 
the  cost  problem,  a  good  potable  water  being  supplied  for  drinking 
and  general  household  purposes,  and  a  less  costly  water  (river  water 
for  civic  uses,  fire,  street  washing,  etc. ) .  This  method  is  at  present 
used  in  several  European  cities  {e.g.,  Paris).  If  this  latter  supply 
for  commercial  and  civic  uses  were  treated  in  a  way  to  render  it 
safe  (adding  hypochlorites  or  chlorine),  or  unattractive  for  food 
and  drinking  purposes  (by  affecting  the  color  or  taste),  there  could 
be  little  objection  to  the  double  supply. 

There  are,  on  the  other  hand,  strong  arguments  for  a  minimum 
water  rate  which  will  allow  sufficient  water  for  ordinary  family  use. 
The  very  poor  tend  to  cut  down  too  much  the  water  consumption. 
This  is  distinctly  a  disadvantage  to  the  community,  as  too  great  a 
limitation  predisposes  to  disease;  this  both  directly  and  indirectly 
affects  the  health  of  the  whole  community. 

Bottled  Waters, — Bottled  drinking  waters  are  of  two  main 
kinds:  (1)  Distilled  water  to  which  the  bottling  firms  add  minerals 
"to  taste,"  and  (2)  natural  spring  waters.  The  former  are  usually 
bacteriologically  safe,  though  there  are  on  record  occasional  cases 
of  mishandling,  such  as  illicit  refilling  of  emptied  bottles.  Charged 
waters  are  "charged"  with  gas,  often  COg  gas.  Such  charged 
waters  are  often  sterile. 

Waters  from  various  springs  containing  water  of  attractive  taste 
or  real  or  imagined  therapeutic  values  form  the  other  type  of  bottled 
waters.  There  is  a  tendency  to  use  much  the  same  names  for  dis- 
tilled and  for  these  natural  waters — commonly  some  combination 
of  "  Lake,"  "  Spring,"  or  "  Hygeia."  The  safety  of  such  waters 
varies  with  the  hygienic  conditions  of  the  spring  and  the  bottling 
processes. 

Too  often  the  spring  is  an  unprotected  hole  in  the  ground  sub- 
ject to  surface  washings,  open  to  children  and  domestic  animals 


WATER 


113 


(Fig.  32) ;  the  bottling  is  often  done  most  carelessly — sometimes 
by  children !  These  natural  waters  are  subject  to  the  risks  already 
mentioned  from  improper  handling  after  bottling.  Patrons  should 
insist  on  being  supplied  with  bottles  with  unbroken  seals. 

Those  using  bottled  water  can  usually  secure  from  the  city  or 
State  department  of  health  a  report  regarding  the  safety  of  the 
water  in  which  they  are  interested ;  in  some  cities  the  sanitary  code 
defines  definitely  the  grade  of  bottled  water  that  may  be  sold.     In 


Fig.   32. — A  spring  from  whirh  water  was  bottled  for  sale.     Note  the  opportunity  for 
surface  drainage  from  the  road  and  house  just  above  the  rough  shack  surrounding  the  spring. 


New  York  City  the  restrictions  are  very  definite :  "  It  shall  be  the 
duty  of  every  manufacturer^  importer  or  other  person  who  manu- 
factures or  imports,  in  the  City  of  New  York,  any  artificial  or 
natural  mineral,  spring  or  other  water  for  drinking  purposes,  to 
file,  under  oath,  with  the  Department  of  Health,  the  name  of  such 
water  and  the  exact  location  from  which  it  is  obtained,  together 
with  the  chemical  and  bacteriological  analysis  thereof,  and  when 
manufactured,  the  exact  formula  used  in  its  production,  giving 
qualitatively  and  quantitatively  each  and  every  item  entering  into 
its  composition.  No  person  shall  manufacture  or  bottle  mineral, 
carbonated  or  table  waters,  in  the  City  of  New  York,  without  a 
permit  from  the  Board  of  Health." 


114  HOME  AND  COMMUNITY  HYGIENE 

PROBLEMS 

1.  What  is  the  source  of  the  water  used  in  your  town?  What  means 
(storage,  chemicals,  etc.)  are  used  to  make  it  safe?  How  often  is  it  tested 
as  ^o  its  chemical  and  bacterial  condition? 

2.  How  many  of  your  public  buildings  (schools,  railroad  stations,  etc.) 
still  use  or  allow  public  drinking  cups? 

3.  To  whom  can  your  community  apply  to  ascertain  the  cause  of 
"hardness"  in  your  water  supply  and  the  way  it  can  most  economically 
be  reduced? 

4.  To  Avhat  public  official  in  your  city  (or  State)  can  you  apply  for  a 
free  test  of  the  public  drinking  water  from  a  bacteriological  standpoint? 
Can  private  supplies  be  tested  also? 

5.  Are  the  swimming  pools,  wading  pools,  and  other  public  bathing 
places  in  your   community   safeguarded  in  any  way? 

6.  Write  a  popular  argument  designed  to  secure  sanitary  control  of 
swimming  pools,  bathing  places,  etc. 

7.  What  is  the  source  of  your  local  ice  supply?  Do  you  consider  it 
safe? 

8.  Debate  the  advantages  of  a  metered  water  supply  versus  a  minimum 
charge  per  family. 

9.  A  city  in  Michigan  boils  all  the  water  supplied  its  inhabitants.  Has 
your  city  a  cheaper  or  a  safer  method? 

10.  Mechanical  filtration  is  used  for  many  city  supplies.  Chemical 
coagulants  are  always  added  to  the  water;  the  filters  are  made  of  sand,  in 
tanks,  etc.,  constructed  to  facilitate  washing  of  the  sand,  e.g.,  reversal  of 
the  flow.  The  process  is  100  to  200  times  as  rapid  as  the  slow  sand  filters, 
(p.  106).  being  a  mechanical  straining  rather  than  a  biological  process  as 
described  on  p.  156.  Consult  the  comparative  table  in  Rosenau  for  the 
relative  merits  of  the  two  types  of  filters. 

See  Reference  List  at  end  of  Appendix. 


CHAPTEE  VI 
AIR  AND  VENTILATION 

Introduction. — The  supreme  importance  of  fresh  air  is  not  to 
be  questioned;,  yet  there -is  no  phase  of  our  environmental  relation- 
ship so  little  understood  nor  so  misunderstood.  Most  people  even 
to-day  think  only  of  the  chemical  constituents  of  the  air  {e.g., 
oxygen,  carbon  dioxide)  and  fail  to  recognize  the  greater  im- 
portance of  its  physical  condition,  e.g.,  temperature,  humidity. 

Important  scientific  commissions  in  the  United  States  and 
Europe  have  tested  the  effects  of  various  combinations  of  atmos- 
pheric characters  (e.g.,  different  percentages  of  oxygen,  humidity, 
and  temperature)  on  human  subjects  confined  in  specially  con- 
structed chambers  in  which  the  conditions  could  be  modified  at  will, 
and  there  is  no  doubt  that  the  three  primary  factors  affecting  our 
comfort  are  temperature,  humidity,  and  air  movement.  The  move- 
ment of  the  air  is,  of  course,  important  only  because  it  brings  to  the 
body  layers  or  masses  of  air  differing  in  humidity  or  temperature. 

Bacteria  in  Air. — -The  bacterial  content  of  the  air  has  an  im- 
portant bearing  upon  health.  It  is,  perhaps,  the  simplest  of  all  the 
relationships  of  air,  and  may,  therefore,  be  discussed  first,  espe- 
cially as  it  bears  little  direct  relation  to  the  other  factors. 

The  bacteria  in  the  air  come  mainly  from  the  soil,  plant  and 
animal  decay,  fermenting  substances,  and  animal  discharges  (saliva, 
fgeces).  Bacteria  do  not  ordinarily  multiply  in  the  air,  for  a  liquid 
or  semi-liquid  medium  is  usually  necessary,  such  as  milk,  cooked 
foods,  blood,  and  plant  or  animal  tissues.  While  it  is  conceivable 
that  growth  might  continue  for  a  time  in  such  substances  as  expec- 
torated masses  of  sputum,  the  air  is  a  place  where  bacteria  diminish 
in  number  rather  than  increase.  The  rate  at  which  they  disappear 
from  the  air  would  depend  upon  conditions  met  there.  Extreme 
cold,  intense  sunlight,  and  lack  of  moisture  tend  to  hasten  the 
death  of  air  organisms.  Under  favorable  conditions  over  90  per 
cent,  of  the  bacteria  may  die  in  twenty-four  hours;  this  would  not 
be  true  of  spore-bearing  organisms,  nor  of  bacteria  covered  by 

115 


116  HOME  AND  COMMUNITY  HYGIENE 

phlegm,  etc.  Their  own  weight,  minute  as  they  are,  causes  them  to 
"sediment  out"  of  the  air,  though  rapid  movements  of  the  air  tend 
to  petard  their  settling  to  the  earth,  where  they  are  caught  and  held 
by  wet  surfaces,  e.g.,  lakes.  Their  suspension  in  the  air  is  also  pro- 
longed by  lint  or  dust  particles,  which  may  act  as  floaters  or  buoys. 
Eain,  snow,  and  heavy  fogs  wash  out  of  the  air  not  only  bacteria, 
but  also  floating  particles  which  favor  their  suspension. 

Eeviewing  the  statements  in  the  last  paragraph,  it  will  be  easily 
understood  why  the  bacterial  content  of  the  air  varies  with  the 
locality,  lower  counts  ^  per  cubic  foot  being  obtained  in  the  first  of 
each  of  the  following  paired  situations:  high  and  low  altitudes; 
country  and  city;  ventilated  rooms  and  dusty  streets;  ocean  and 
land;  moist  and  dry  climates;  after  and  before  rain  storms.  The 
range  in  number  is  very  great ;  often  none  at  all  in  a  cubic  foot  on 
a  mountain  top  or  glacier  or  at  the  seashore,  and  thousands  (10,000 
or  more)  in  a  cubic  foot  in  crowded,  dusty  rooms. 

Transfer  Through  Air. — Most  of  the  bacteria  in  the  air  are 
harmless  to  man.  Even  where  the  number  reaches  hundreds  and 
thousands  per  cubic  foot,  one  may  breathe  such  air  without  acquir- 
ing any  specific  infection.  It  is  estimated  that  under  normal  condi- 
tions about  300,000  bacteria  are  taken  in  per  day  in  the  inspired 
air.  The  tissues,  therefore,  have  enough  to  do  in  disposing  of  the 
average  number  of  air  bacteria  without  subjecting  them  to  increased 
work  by  breathing  air  heavily  charged  with  bacteria.  Many  bac- 
teria are  mechanically  removed  from  the  inspired  air  by  the  nasal 
secretions,  many  are  carried  by  food  and  mucus  on  down  into  the 
intestinal  canal,  but  many  are  possible  agents  of  evil,  adhering  to 
the  nasal,  pharynx,  tonsil,  and  lung  membranes.  Many  are  doubt- 
less oxidized  (Gr)  in  the  lungs,  and  some  of  the  cells  composing  the 
fine  air  sacs  or  alveoli  are  quite  like  the  white  corpuscles  in  their 

'  The  bacteria  in  air  are  counted  by  pumping  through  some  kind  of 
collecting  or  filtering  substance  (such  as  water)  a  given  amount  of  the 
air  to  be  tested  ( e.g.,  one  cubic  foot,  one  cubic  meter ) .  The  bacteria  and 
other  solids  are  thus  collected,  sedimented  by  allowing  the  water  to  stand, 
or  by  centrifuging  (G)  it,  and  the  sediment  is  used  to  make  an  agar  (G) 
plate  which  is  incubated  for  two  or  three  days  to  allow  the  bacteria  from 
the  air  sample  to  develop  intO'  colonies.  A  simpler,  but  much  less  satis- 
factory, method  of  estimating  the  bacteria  in  air  is  to  uncover  a  plate  of 
agar  for  three  to  five  minutes,  and  then  close  and  incubate  the  plate.  Air 
currents  alone  modify  the  results  obtained  by  this  method  so  greatly  that 
it  is  not  an  accurate  method  of  testing  air. 


AIR  AND  VENTILATION  ]17 

destructive  effect  upon  bacteria,  having  the  same  power  of  engulfing 
and  digesting  bacteria. 

Forcible  expiration,  such  as  loud  whispering,  coughing,  and 
sneezing,  discharges  into  the  air  small  particles  of  saliva,  mucus, 
etc.,  rich  in  bacteria.  Considerate  people  prevent  the  wide  distri- 
bution of  such  bacteria  by  covering  the  mouth  with  the  hand  or 
handkerchief.  This  implies  numerous  fresh  handkerchiefs,  frequent 
washing  of  the  hands,  etc.  It  is  little  protection  to  society  to  so 
oover  the  mouth,  if  the  unfortunate  offender  otherwise  forces  on 
his  neighbor  or  family  direct  contact  with  the  undesirable  organ- 
isms (sore  throat,  pneumonia,  colds,  etc.)  by  careless  handling  of 
dishes,  food,  or  their  personal  belongings,  such  as  handkerchiefs. 

Usually  but  a  small  proportion  of  the  bacteria  found  in  air  are 
able  to  cause  disease  in  man.  This,  of  course,  may  not  be  true  of 
air  heavily  polluted  by  the  discharges  of  the  sick  {e.g.,  sputum 
from  the  tubercular,  nasal  excretions  of  those  beginning  with 
measles).  In  crowded  places,  such  as  cars,  a  sneezing  neighbor  may 
so  pollute  his  immediate  environment  (within  a  radius  of  ten  to 
twelve  feet  or  more  when  air  currents  favor  such  distribution)  that 
he  is  a  serious  menace  to  those  near  him,  since  live  and  vigorous 
organisms  may  be  thus  directly  planted  upon  the  nasal  and  throat 
membranes  of  his  neighbors.  Such  bacteria  may  by  some  be  con- 
sidered "  air-borne,"  but  they  are  practically  transferred  by  direct 
contact.  There  is  great  doubt  whether  any  diseases  are  really  air- 
borne, though  smallpox  and  measles,  about  which  little  is  definitely 
known,  are  still  sometimes  classed  as  air-borne.  In  fact,  bacteria 
are  so  short-lived  in  air  that  the  dangers  of  transfer  by  air  in  home 
and  hospital  have  been  greatly  exaggerated  (see  pp.  169  to  187). 

Constant  Temperature  for  Warm-blooded. — Man  and  other 
warm-blooded  animals  must  maintain  a  relatively  constant  body 
temperature,  despite  great  and  often  rapid  fluctuations  in  the  sur- 
rounding atmosphere.  In  man,  but  slight  variations  from  the  nor- 
mal internal  temperature  of  37°  C.  (98°  F.)  are  compatible  with 
health,  whether  he  is  working  in  four  shifts  at  the  stoker's  furnace 
at  121°  C.  (250°  F.)  or  braving  for  months  the  cold  of  the  Arctic 
regions  at  -46°  C.  (-50°  F.).  To  retain  the  normal  body  tempera- 
ture demands  perfect  correlation  of  the  regulatory  mechanism  (in- 
cluding the  nervous,   circulatory,   respiratory,   and   excretory   sys- 


118  HOME  AND  COMMUNITY  HYGIENE 

terns)  to  the  varying  outside  conditions;  all  this  often  in  spite  of 
the  handicaps  of  insufficient  or  excessive  food  supply. 

While  it  is  really  impossible  wholly  to  separate  temperature  and 
humidity  in  discussing  body  temperatures,  it  seems  advisable  here 
to  begin  with  temperature  as  if  it  were  possible  to  consider  them 
singly. 

Normal  Body  Temperature. — Somewhere  between  17°  C. 
(62°  F.)  and  21°  C.  (70°  F.)  practically  every  normal  individual 
finds  his  optimum  atmospheric  temperature.  As  this  is  very  much 
lower  than  the  average  body  temperature,  37°  C.  (98°  F.),  it  indi- 
cates that  in  sustaining  37°  C.  as  an  average  the  body  is  constantly 
losing  a  large  amount  of  heat,  and  therefore  producing  much  more 
heat  than  is  implied  when  we  speak  of  37°  C.  as  the  body  tem- 
perature. And  the  increased  heat  production  necessary  when  the 
body  is  surrounded  by  still  lower  temperatures — zero  weather,  for 
instance — ^must  be  very  great,  even  though  the  usual  elimination  of 
heat  from  the  body  is  then  greatly  reduced  by  extra  or  heavier 
clothing.  At  the  higher  temperatures  of  midsummer  or  of  over- 
heated rooms,  the  body  efforts  are  in  the  opposite  direction :  heat 
production  in  the  body  must  be  minimized  and  the  elimination  of 
heat  from  the  body  must  be  expedited  very  greatly,  if  the  body  tem- 
perature is  kept  down  to  37°  C. 

Heat  is  produced  in  the  animal  body  mainly  by  the  oxidation  of 
food  substances.  This  indicates  the  basal  importance  of  food — not 
food  en  masse  nor  food  in  the  alimentary  canal  merely — ^but  di- 
gested food,  or  food  in  absorbable  form  which  is  distributed  by  the 
blood  (and  lymph)  to  all  the  living  cells  of  the  body.  In  each  of 
these  cells  much  of  this  food  is  oxidized  by  oxygen  carried  to  them 
by  the  blood.  This  oxidation  yields  energy  or  the  power  to  do 
work.  The  energy  production  is  coincident  with  the  production  of 
heat.  This  heat  varies  with  the  amount  of  work  done  by  those 
cells,  and  with  the  kinds  of  cells  most  actively  employed :  a  resting 
muscle  produces  much  less  heat  than  one  in  action ;  less  evidence  of 
heat  is  obtained  from  extreme  activity  of  brain  cells  than  from 
even  moderate  activity  of  gland  or  muscle  cells.  It  will,  therefore, 
be  clear  that  heat  produced  may  not  only  be  limited  by  the  amount 
of  food  and  oxygen  available,  but  that  it  is  influenced  also  by  the 
work  done. 

Heat  Loss. — Heat  is  lost  or  eliminated  from  the  body  in  sev- 


AIR  AND  VENTILATION  119 

eral  ways:  first,  by  the  elimination  of  such  warm  body  wastes  as 
expired  air,  urine,  and  faeces;  second,  by  the  evaporation  of  water 
from  the  surface  of  the  body;  third,  by  the  direct  passage  of  heat 
itself  from  the  body.  The  first  is,  of  course,  considerable,  but  it  is 
more  or  less  compensated  for  by  the  high  temperature  of  certain 
foods  when  eaten  {e.g.,  hot  soups).  The  second  is  more  important. 
To  change  water  to  water  vapor  demands  heat.  A  given  amount  of 
heat  is  necessary  to  vaporize  a  given  amount  of  water,  whatever  the 
conditions :  it  may  be  applied  quickly  or  slowly ;  it  may  be  in  visible 
form,  as  burning  gas ;  or  one  may  be  unconscious  of  its  presence  and 
action,  as  the  evaporation  of  water  by  the  sun  on  a  mild  day,  and 
the  evaporation  of  water  from  the  surface  of  the  body  by  the  heat 
of  the  body  itself  or  by  the  heat  of  the  surrounding  air.  Every 
twenty-four  hours  nearly  two  quarts  of  water  pass  from  the  body  as 
insensible  perspiration;  the  heat  which  vaporizes  it,  rendering  it 
"  insensible,"  is  taken  from  the  warm  body  or  the  air  immediately 
surrounding  the  body.  Insensible  perspiration  probably  means  a 
daily  loss  of  nearly  500  calories  (G).  The  third,  the  direct  passage 
of  heat  itself,  is  commonly  discussed  in  physics  under  three  topics : 
conduction,  convection,  and  radiation.  The  meaning  of  these  terms 
forms  the  real  basis  of  a  complete  understanding  of  heat  elimina- 
tion and  conservation  as  well;  they  are  also  fundamental  in  under- 
standing the  applications  of  this  question  to  ventilation. 

Conduction. — Heat  varies  in  the  rapidity  with  which  it  can 
travel  through  various  substances,  from  particle  to  particle.  It 
travels  quickly  through  iron  and  silver,  slowly  through  air  and  glass. 
Iron  is,  therefore,  a  good  conductor ;  air,  a  poor  conductor.  Simi- 
larly, linen  is  a  better  conductor  than  cotton  and  silk ;  to  conserve 
the  body  heat,  one  would  not  choose  linen  for  the  clothing  in  con- 
tact with  the  skin.  Since  air  is  a  poor  conductor,  a  layer  of  air  may 
make  a  warmer  covering  than  textiles.  To  keep  that  layer  of  air 
unbroken,  an  outer  layer  of  clothing  is  necessary.  Several  layers 
of  clothing  mean  several  such  non-conducting  air  layers,  each  one 
hindering  the  passage  of  heat  from  the  body.  Instead  of  several 
complete  layers  of  air,  similar  results  may  be  obtained  by  a  loosely- 
meshed  material  which  has  in  its  single  thickness  innumerable  little 
air  spaces ;  some  types  of  underwear,  sweaters,  "  hug-me-tights," 
and  woolen  textiles  in  general,  owe  their  '^  warmth  "  to  these  air 
spaces.    The  layer  of  air  next  the  body  becomes  somewhat  heated 


120  HOME  AND  COMMUNITY  HYGIENE 

from  contact  with  the  body,  by  conduction.  If  the  same  "  aerial 
blanket'"'  can  be  maintained,  the  body  heat  loss  is  less  than  if  new 
layers  have  to  be  heated  at  the  body's  expense.  (This  "aerial 
blanket"  is  often  used  in  a  broader  way,  meaning  the  general  air 
layer  around  the  body,  clothing  and  all.) 

Convection. — The  air  around  the  body,  on  becoming  heated,  is, 
of  course,  lighter,  bulk  for  bulk,  than  the  surrounding  cooler  air. 
It  is  pushed  up  or  farther  away  by  the  heavier  cooler  air,  thus 
forming  currents  called  convection  currents;  this  method  of  dis- 
tributing heat  is  called  convection.  Since  convection  changes  the 
"  aerial  blanket,"  it  is,  of  course,  a  definite  help  in  warm  weather ; 
but,  even  then,  we  prefer  to  break  or  replace  our  "  aerial  blankets  " 
more  rapidly  or  effectually  by  walking,  bicycling,  motoring,  or  by 
the  use  of  fans,  hand  or  electric.  At  times  the  replacing  air  may  be 
so  nearly  the  temperature  of  the  former  body  layers  of  air  that  prac- 
tically no  heat  is  conducted  from  the  body  and  no  change  of  tem- 
perature is  noticed.  In  walking,  running,  etc.,  the  aerial  blanket  is 
rapidly  broken  or  replaced,  but  the  added  heat  caused  by  the  mus- 
cular exercise  may  more  than  offset  any  small  benefit  so  obtained. 
Convection  is,  of  course,  not  a  different  way  of  removing  heat  from 
the  body,  being  merely  a  way  of  bringing  fresh  layers  of  air  to  the 
body,  each  of  these  fresh  layers  removing  heat  from  the  body  by 
conduction  and  hj  the  evaporation  of  body  moisture. 

Radiation.— Conduction,  and  the  subsequent  convection,  do  not 
account  for  all  the  heat  lost  from  a  heated  body.  Heat  may  pass 
from  a  heated  mass,  not  only  in  currents,  but  irrespective  of  them, 
or  actually  in  opposition  to  such  heat  waves.  Convection  waves  may 
be  noticed  over  a  stove  or  hot  grate,  but  considerable  heat  passes  out 
in  all  directions,  e.g.,  horizontally  and  downward,  from  that  same 
heated  mass,  the  heat  travelling  across  or  even  against  the  convec- 
tion waves.  It  may  also  be  observed  in  a  vacuum,  where  there  is  no 
air  to  act  as  a  conductor,  or  form  convection  waves.  The  theory 
that  the  heat  travels  on  the  ether  (G)  waves  accounts  not  only  for 
this  method  of  heat  dissemination  here  on  our  earth,  but  for  the 
passage  of  the  sun's  heat  through  space  to  the  earth.  Eadiation, 
like  conduction,  decreases  vfith.  a  rise  in  temperature  (see  p.  148). 
At  usual  room  temperatures  conduction  and  radiation  account  for 
about  75  per  cent,  of  the  loss  of  body  heat,  or  about  1800  calories. 

Adaptation  to  Low  Temperatures. — When  we  are  exposed  to 


AIR  AND  VENTILATION  121 

low  outside  temperatures  the  problem  is  to  conserve  body  heat:  to 
lessen  the  conduction  of  heat,  to  hinder  convection  currents  in  re- 
moving the  body-heated  layers  of  air,  and  to  check  or  decrease  radia- 
tion. There  is  but  one  other  alternative — to  produce  more  heat  in 
the  body.  This  can  be  done  by  using  the  storage  food  {e.g.,  fat),  or 
by  taking  in  more  food.  If  the  diet  is  already  sufficient  m  amount 
and  well-proportioned  {e.g.,  the  right  proportion  of  heat-producing 
foods),  no  great  change  should  be  made  in  the  food  supply,  for 
there  is  great  danger  that  a  heavier  food  intake  will  overwork  the 
digestive  and  related  systems.  The  diet  should  always  be  modified 
according  to  the  season,  the  work  done,  and  the  storage  or  reserve 
food  that  may  safely  be  drawn  upon;  but  modifications  in  dress, 
and  a  careful  consideration  of  the  length  and  extremity  of  periods 
of  exposure,  are  more  economical  and  also  safer  ways  of  maintain- 
ing the  necessary  body  temperature  than  making  heavy  additions  to 
the  amount  eaten. 

Meeting  High  Temperatures. — At  temperatures  approaching 
and  exceeding  body  temperatures  the  problem  is  the  opposite  of 
that  just  discussed.  Effort  is,  therefore,  made  to  favor  the  elimina- 
tion of  heat  from  the  body.  Good  conductors  {e.g.,  linen)  are  pre- 
ferred for  clothing,  especially  that  in  contact  with  the  body.  The 
frequent  or  definite  replacement  of  the  air  blanket  is  assured  by 
leaving  much  of  the  body  uncovered,  by  wearing  fewer  layers  of 
clothing,  and  by  the  instinctive  resort  to  fanning,  seeking  cooler 
corners,  etc.  Here,  too,  the  result  may  also  be  affected  by  the 
amount  of  heat  produced  in  the  body.  A  lessened  food  intake 
means  less  oxidation.  (Stored  food,  e.g.,  fat,  may,  of  course,  be 
oxidized,  if  called  for  by  exercise  demanding  more  than  the  reduced 
food  intake,  and  no  diminution  in  heat  production  observed.) 
While  reduction  of  diet  may  be  carried  too  far,  the  cases  of  in- 
jurious voluntary  reduction  are  few  when  compared  with  the  cases 
of  overeating. 

Internal  Regulation  of  Body  Temperature. — Our  discussion 
has  implied  that  by  such  external  mechanical  devices  we  can  con- 
sciously control  our  physical  comfort  in  this  matter  of  temperature 
adjustment.  Yet  the  greater  part  of  the  adjustment  is  made 
tlirough  the  involuntary  activity  of  the  nervous,  circulatory,  re- 
spiratory, and  excretory  systems.  Without  the  constant  cooperation 
of  these   closely   correlated   involuntary   systems,   though   we   con- 


122  HOME  AND  COMMUNITY  HYGIENE 

sciously  devoted  every  minute  of  our  time  to  meeting  the  various 
and  varying  external  temperatures,  modifying  to  this  end  our  diet, 
our  clothing,  our  body  movements,  and  availing  ourselves  to  the 
full  of  our  knowledge  of  heat  conservation  and  dissipation,  we  would 
not  pass  one  comfortable  hour  in  the  whole  twenty-four.  As  a 
matter  of  fact,  before  we  are  conscious  that  the  temperature  has  in- 
creased or  fallen,  the  nervous  system  has  started  compensatory  cor- 
related action  in  these  systems.  The  skin  capillaries  may  be  con- 
tracted to  lessen  circulation  in  the  skin  and  conserve  body  heat  by 
reducing  the  amount  of  blood  near  the  surface  of  the  body  and 
opportunities  for  conduction;  or  the  skin  capillaries  may  become 
enlarged  (1)  to  allow  greater  elimination  of  heat  from  the  body 
(and  reduce  the  dangerously  high  temperature  obtaining  in  the 
internal  organs) ;  or  (2)  to  insure  greater  heat  supply  in  the  skin 
where  the  temperature  may  be  dangerously  low.  Such  skin  changes 
are  accompanied  by  changes  in  the  rate  of  circulation  and  in  the 
depth  and  rate  of  respiration.  Increased  or  decreased  blood  supply 
in  any  region  means  increased  or  decreased  cell  food  and  oxygen, 
with  proportionate  changes  in  cell  oxidation  and  heat  production. 
The  excretory  system  is  directly  affected;  this  is  illustrated  by  the 
increased  or  diminished  water  output  from  the  lungs  and  the  skin. 

The  detailed  discussion  of  these  relationships  belongs  to  physi- 
ology rather  than  hygiene.  Some  of  us,  however,  may  find  it  in- 
teresting to  consider  here  such  questions  as  the  following:  Why 
do  such  different  causes  as  exercise,  cold  winds,  and  midsummer 
heat  all  flush  the  skin?  In  long  exposures  to  cold,  why  is  a  dan- 
gerous condition  indicated  when  the  flushed  skin  becomes  pallid? 
Does  a  hot  or  cold  bath  bring  greater  or  more  lasting  relief  from 
excessive  summer  heat  ?  Does  a  person  who  doesn't  perspire  readily 
really  feel  the  heat  less  ? 

Dress  and  Thermal  Control, — While  we  cannot  by  taking 
thought  add  much  to  the  compensatory  power  of  these  related  sys- 
tems, it  is  unfortunately  within  our  power  to  lessen  materially  their 
prompt  and  complete  response  to  the  body  needs.  One  may  so 
nearly  protect  one's  self  from  variations  in  external  temperature 
by  too  heavy  clothing  or  too  many  layers  of  clothing,  or  by  "  keeping 
housed  up,"  that  the  skin  experiences  but  few  and  slight  changes  in 
temperature,  and  practically  loses  its  power  to  respond  quickly 
to  changing  conditions.       An  overheated,  covered  skin  often  be- 


AIR  AND  VENTILATION  123 

comes  flabby  and  moist;  the  chill  due  to  this  condensed  moisture 
may  lead  one  to  think  that  his  skin  is  particularly  sensitive  to  cold, 
and  that  he  would  perish  absolutely  under  normal  conditions, 
whereas  he  would  be  much  more  comfortable  with  less  clothing,  or 
if  he  subjected  himself  more  often  to  outdoor  conditions.  Old 
people  (whose  metabolic  and  compensatory  processes  are  slowed), 
inactive  people,  and  nervous  invalids,  may  be  commonly  observed 
increasing  their  own  discomfort  by  such  prejudices.  But  less  sym- 
pathy is  felt  for  those  whose  blind  adherence  to  style  leads  them  to 
wear  excessively  heavy  clothing  indoors  or  throughout  the  summer. 
Just  as  men  had  acquired  a  fair  degree  of  tolerance  for  the  clean 
and  attractive  negligee  shirt,  women  set  back  such  common-sense 
customs  indefinitely  by  the  silly  slogan,  "iSTo  lady  is  seen  on  the 
street  without  her  coat.''  Just  as  foolish  is  the  constant  wearing  of 
sport  coats  and  sweaters  in  overheated  rooms  and  even  in  mid- 
summer. No  cut  or  color  of  outer  garment  can  outweigh  in  any 
observer's  eyes  the  evidences  of  bodily  discomfort  and  often  un- 
cleanliness  common  to  such  inappropriately  dressed  people. 

One  other  factor  afEecting  heat  elimination  might  well  be  men- 
tioned here.  Fat  conducts  heat  less  readily  than  other  tissue. 
Those  who  have  a  definite  fatty  layer  beneath  the  skin  do  not  lose 
internal  body  heat  as  rapidly  as  those  lacking  such  a  layer.  There 
are,  in  winter  time,  certain  advantages  in  being  fat.  In  summer, 
how  would  such  a  fatty  layer  affect  one's  comfort?  Women  have 
usually  a  more  definite  fatty  layer  than  men.  Many  of  the  house- 
hold disagreements  as  to  the  optimum  house  temperature  may  be 
traced  to  this  difference,  though,  naturally,  the  relative  physical 
activity  of  the  various  members  of  the  household  has  a  great  deal  to 
do  with  it. 

Variations  in  Temperature  Desirable. — Periodic  and  marked 
variations  in  temperature  (indoors  as  well  as  outdoors)  are  most 
desirable.  In  that  way  only  can  the  skin  keep  its  power  or  habit  of 
instant  and  full  response.  The  habit  of  running  outdoors  with- 
out a  wrap  or  hat  for  irief  periods  of  time  is  usually  better  than  a 
tonic  in  its  stimulating  effect  on  the  body  through  its  complex  com- 
pensator}'-  mechanism.  The  cold  spray  at  the  end  of  the  shower 
bath  is  a  common  way  of  helping  the  skin  retain  its  important 
function  as  a  thermal  regulator. 

Hinnidity. — Having   discussed   temperature    and   its    applica- 


124  HOME  AND  COMMUNITY  HYGIENE 

tions,  our  problem  now  is  a  relatively  simple  one,  and  consists  of  but 
two  parts:  (1)  What  we  mean  by  humidity,  and  (2)  how  humidity 
afl'ects  the  dissemination  of  heat  from  the  body.  Mixed  with 
the  air  is  a  varying  amount  of  water  vapor.  The  amount  depends 
upon  the  water  available  and  upon  the  temperature.  (It  is  cus- 
tomary to  speak  of  air  as  "  holding  "  water,  though  the  amount  of 
water  in  a  given  space  is  independent  of  the  presence  of  air.) 
Roughly  measured,  air  at  room  temperature,  17°  C.  (62°  F.),  may 
hold  twice  as  much  water  vapor  as  air  at  freezing,  0°  C.  (33°  F.), 
and  three  times  as  much  at  body  temperature  as  at  freezing. 

The  amount  of  water  present  in  a  given  volume  of  air  is  called 
the  absolute  humidity.  It  is,  for  some  reason,  more  common  to 
measure  humidity  in  terms  of  the  water  really  present  when  com- 
pared with  what  it  might  hold  at  that  temperature.  For  example, 
one  cubic  metre  of  air  at  30°  C.  (86°  F.)  can  "hold"  thirty 
grams  of  water  vapor.  If  in  this  space  the  air  at  30°  C.  has  but 
twenty-four  grams  of  water  vapor,  its  relative  humidity  is  80 
per  cent.  Where  the  available  water  is  limited  (indoors,  dry 
weather),  there  is  often  a  great  range  in  the  relative  humidity, 
often  as  great  as  80  per  cent,  in  a  day.  In  most  of  our  daily  news- 
papers, relative  humidity  is  given.  The  reading  for  January  28, 
1918,  New  York  City,  is: 

8  A.  M.,  humidity  98  per  cent. 

10  A.  M.,  humidity  88  per  cent. 

3  P.  M.,  humidity  86  per  cent. 

6  P.  M.,  humidity  96  per  cent. 

Since  the  temperature  affects  so  directly  the  amount  of  water 
vapor  in  suspension,  there  are,  throughout  the  day  with  the  chang- 
ing temperatures,  constant  changes  in  the  amount  of  vapor  held. 
Outdoor  air  commonly  contains  from  30  per  cent,  up  to  100  per 
cent,  (or  saturation  (G)).  The  amount  may  regularly  vary  as 
much  as  80  per  cent,  during  one  day  (relative  humidity).  In 
buildings,  the  water  vapor  is  rarely  condensed  to  water  in  sufficient 
amounts  to  attract  attention  (except  on  cold  window  panes).  When 
the  relative  humidity  reaches  80  to  85  per  cent,  it  begins  to  show 
on  the  objects  in  the  room.  Eoom  air  is  commonly  very  much  drier 
than  outdoor  air.  But  the  cold  walls,  while  apparently  dry,  may 
hold  large  amounts  of  water,  sometimes  more  than  all  the  air  space 
in  the  room.      There  is,  therefore,  a  continued  exchange  between 


AIR  AND  VENTILATION  125 

such  chilled  water-holding  walls  and  the  room  air.  In  cold  snaps, 
the  wall  fixtures  (doorknobs,  bolts,  plumbing)  and  the  cold  corners 
of  the  walls  themselves  sometimes  become  covered  with  a  coating  of 
fine  ice  crystals  or  a  feathery,  snowy  mass,  thus  showing  that  much 
water  is  present  on  the  walls,  etc. 

Effect  of  Humidity  on  Body  Temperature. — The  humidity 
of  the  air  affects  the  temperature  of  the  body  in  several  ways:  (1) 
Conduction  takes  place  more  rapidly  as  humidity  increases.  We 
have  long  recognized  this,  saying,  "  There  forty  degrees  below  zero 
isn't  so  cold  as  zero  weather  here,  because  it's  dry  cold,"  or  "  We 
feel  the  cold  more  to-day,  because  it's  damp."  More  rapid  conduc- 
tion means  more  rapid  heating  of  the  air  masses  near  the  body  and 
more  active  convection  currents  carrying  the  heated  air  away  from 
the  body. 

(2)  Eadiation  diminishes  as  the  humidity  increases  (see  p.  148 ) . 

(3)  A  third  way  in  which  humidity  affects  body  temperatures 
is  that  it  affects  the  evaporation  of  moisture  from  the  body.  Air 
saturated  with  water-vapor  cannot  (at  that  same  temperature)  re- 
ceive any  water  vapor  from  the  body.  High  humidity,  therefore, 
lessens  the  evaporation  of  body  moisture  and  therefore  hinders  the 
loss  of  heat  from  the  body.  A  room  that  is  too  cold  for  comfort  may 
sometimes  be  made  quite  comfortable  by  boiling  water  in  the  room, 
mainly  because  then,  in  the  more  humid  atmosphere  established, 
the  body  loses  less  heat  by  the  evaporation  of  body  moisture.  (This 
apparently  more  than  counteracts  the  increased  conductivity  of 
humid  air  mentioned  above.) 

In  hot  weather  when  atmospheric  temperatures  (indoors  and 
out)  are  as  high  or  higher  than  the  body  temperature,  we  get  little 
relief  by  the  conduction  and  convection  of  heat;  but  if  the  air  is 
relatively  dry,  comparatively  large  amounts  of  body  moisture  can 
be  changed  to  vapor,  thus  materially  reducing  the  temperature  of 
the  body  and  of  the  air  in  contact  with  it.  Such  devices  as  sprink- 
ling floors,  wetting  sheets,  or  other  large  areas  with  water  increase 
the  humidity,  but  they  also  reduce  the  temperature  by  the  evapora- 
tion of  the  water,  especially  when  an  electric  fan  increases  the  air 
circulation,  and  therefore  the  opportunities  for  evaporation.  A 
little  less  water  may  be  evaporated  from  the  skin,  but  this  con- 
sequent reduction  in  the  personal  loss  of  heat  is  more  than  com- 


126  HOME  AND  COMMUNITY  HYGIENE 

pensated  for  by  the  general  reduction  in  the  air  temperature  and 
the  increased  conductivity  of  the  air. 

^  The  Comfort  Zone. — In  life,  humidity  and  temperature  are, 
of  course,  coexistent  factors,  and  so  must  be  considered  together. 
Experiments  with  specially  constructed  observation  rooms  have 
shoTHi  that  an  uncomfortably  warm  atmosphere  can  be  made  more 
bearable  by  (1)  reducing  the  temperature,  or  (2)  decreasing  the 
humidity,  or  (3)  by  increasing  the  rate  of  air  movement.  The 
Xew  York  State  Commission  on  Ventilation  showed  that  the  same 
degree  of  comfort  is  obtained  by  reducing  the  temperature  one  de- 
gree, the  humidity  one  per  cent.,  or  increasing  the  air  movement 
twenty  feet  per  second.  For  indoor  temperatures  (which  are  the 
only  ones  we  really  try  to  control)  a  "  comfort  zone "  has  been 
defined;  the  temperature  lies  between  13°  and  21°  C.  (55°  and 
70°  F.),  and  the  humidity  ranges  from  30  to  55  per  cent.,  a  much 
lower  relative  humidity  than  that  found  in  outdoor  conditions. 
There,  however,  the  temperatures  are  usually  lower. 

Effect  of  Types  of  Air. — In  general,  dry  air  is  tonic  and 
stimulating;  so  is  cold  air.  Warm  air  is  depressing  and  moist  air 
is  even  more  so.  Dry,  cool  air  is  usually  desired  for  outdoor  con- 
ditions and  has  the  tonic  and  stimulating  effects  attributed  to 
both  dry  and  cold  air.  In  dry,  warm  air  one  is  usually  conscious 
of  stimulating  effects.  Indoor  air  may  be  so  dry  that  the  evapora- 
tion of  water  from  the  body  is  rapid  enough  to  produce  chills;  if 
20°  C.  (68°  F.)  is  not  warm  enough,  the  room  humidity  is  too  low 
and  should  be  increased  by  boiling  water,  by  leaving  exposed  trays 
of  water  on  the  radiators,  or  through  growing  plants  (for  moisture 
is  given  out  from  the  soil  and  also  through  the  leaves).  Most  of 
the  efforts  to  supply  sufficient  moisture  are  not  successful,  because 
the  water  surface  exposed  is  too  small,  whether  water  is  placed  in 
dishes  on  the  radiators  or  in  the  water-boxes  of  the  furnaces  (see 
p.  143).  In  moist,  warm  air  the  heat  is  not  lost  from  the  body 
rapidly  enough,  the  skin  struggles  to  accomplish  the  increased 
amount  of  work  left  to  it;  the  whole  compensatory  apparatus  may 
be  overworked  (often  adding  definitely  to  the  temperature  discom- 
fort), and  unless  clothing,  exercise,  and  all  muscular  effort  are  de- 
creased sufficiently  to  meet  the  situation,  heat  stroke  may  result. 
Disinclination  to  mental  and  physical  work  (sometimes  also  to 
eating)  characterizes  the  human  response  to  days  or  to  localities  un- 
usually warm  and  moist. 


AIR  AND  VENTILATION  127 

Cold;,  damp  air  makes  a  greater  drain  upon  the  body,  not  because 
of  anything  inherently  injurious  in  dampness,  but  because  both 
dampness  (humidity)  and  cold  encourage  heat  loss  unduly.  While 
modifications  in  clothing  and  increased  exercise  may  help  somewhat 
in  this  situation,  the  usual  resort  is  to  a  heavier  food  intake.  This 
taxes  practically  all  the  important  systems  of  the  body,  and  may 
lead  to  various  derangements  of  one  or  more  organs  {e.g.,  heart, 
kidneys).  The  kidneys  may  be  directly  afEected  by  overwork  due 
to  the  lessened  elimination  of  water  from  the  skin.  Certain  dis- 
eases, e.g.,  pneumonia,  are  more  common  in  cold,  damp  weather, 
due  either  to  a  general  lack  of  tone  or  resistance  resulting  from  the 
above  complications  or  to  conditions  not  yet  wholly  understood. 

Chemical  Substances  in  Air. — We  now  come  to  a  consideration 
of  the  chemical  substances  in  ordinary  air.  Air  is  a  mixture  of 
several  gases,  oxygen,  nitrogen,  and  carbon  dioxide  being  the  most 
important.  There  are  also  small  and  varying  amounts  of  various 
other  gases,  such  as  ozone,  hydrogen  peroxide,  argon,  and  methane. 
Other  chemical  substances,  such  as  acids  and  salts,  found  in  the  air, 
will  be  mentioned  briefly  at  the  end  of  this  section. 

Constancy  o£  Amounts  of  O  and  COg. — ^We  know  that  oxy- 
gen is  constantly  consumed  in  large  amounts  in  all  oxidation  and 
combustion  processes,  such  as  respiration,  the  burning  of  wood,  coal, 
gas,  and  oil.  As  a  result  of  this  oxidation  or  combustion,  carbon 
dioxide  is  formed  in  large  amounts. 

Sugar,  oxidized  in  the  human  body,  breaks  up  into  carbon  diox- 
ide and  water  (CsHi^Oe  +  120->  6CO2  and  SH^O).  Coal  or  any 
other  fuel  substances  burned  in  a  furnace  have  among  their  waste 
substances  large  amounts  of  the  two  products,  COg  and  H^O. 

The  processes  just  described  constantly  remove  from  the  air 
large  amounts  of  oxygen  and  add  to  it  large  amounts  of  carbon 
dioxide.  One  would,  therefore,  expect  to  find  great  differences  be- 
tween the  amounts  of  oxygen  and  carbon  dioxide  in  crowded  cities 
and  unpopulated  districts.  Still  more  might  we  expect  to  find  strik- 
ing contrasts  between  the  air  analyses  made  now  and  those  made 
over  a  century  ago,  when  the  total  population  was  far  less,  and 
when  the  general  use  of  wood,  oil,  gas,  and  coal  in  homes,  and  for 
transportation  and  manufacturing,  was  almost  negligible.  Never- 
theless, the  oxygen  and  carbon  dioxide  proportions  in  the  air  are 
practically  the  same  that  they  were  a  hundred  years  ago. 


128  HOME  AND  COMMUNITY  HYGIENE 

That  the  air  is  so  constant  in  its  proportionate  amounts  of  oxy- 
gen and  carbon  dioxide  is  mainly  due  to  three  things:  First,  the 
total  amount  of  air  is  enormous,  and  our  subtraction  of  oxygen  and 
addition  of  carbon  dioxide  make  very  little  impression  upon  the 
whole  air  layer — smiles  in  depth — which  surrounds  our  earth.  It 
has  been  estimated  that  it  would  take  18,000  years  to  reduce  the 
oxygen  1  per  cent.  Second,  any  gas  difEuses  rapidly  throughout 
the  other  gases  in  this  atmospheric  mixture  we  call  air.  This  dif- 
fusion is  aided  by  the  constantly  changing  air  currents,  e.g.,  winds. 
It  is  only  in  poorly  ventilated  places,  such  as  closed  chambers  and 
deep  recesses,  that  we  find  marked  increases  in  carbon  dioxide,  or 
strikingly  decreased  amounts  of  oxygen.  Despite  the  large  amounts 
of  CO2  given  out  by  furnaces,  etc.,  the  air  of  towns  does  not  differ 
markedly  from  the  country. 

Place  Oxygen  COi 

Country   air    20.94  per  cent.  .6318  per  cent. 

City  air   20.87  per  cent.  .0385  per  cent. 

Third,  green  plants  have  the  peculiar  power  of  utilizing  CO,  in 
their  manufacture  of  sugar  and  starch;  in  doing  this,  oxygen  is 
eliminated  by  the  plant.  With  living  green  plants,  therefore,  we 
have  two  marked  effects  upon  the  air;  carbon  dioxide  is  removed, 
and  oxygen  is  added — twelve  atoms  for  everj  molecule  of  sugar 
formed:  6CO2  from  air  -|-  6II2O  from  soil— >-  GqS.^J^q  (sugar)  -f 
6O2. 

Every  particle  of  green  tissue  in  field,  garden,  or  forest  has 
this  power.  The  millions  of  tons  of  sugars  and  starches  formed 
each  year  by  plants  of  commercial  value  (sugar  cane,  corn,  oats, 
wheat)  give  but  a  partial  idea  of  how  much  carbon  dioxide  is 
broken  up  and  how  much  oxygen  is  released  by  all  the  green  plants 
during  their  active  periods.  It  is  estimated  that  practically  all 
the  oxygen  in  the  CO,  is  released;  and  some  idea  of  the  rate  of  ex- 
change may  be  gained  when  we  read  that  one  square  metre  of  leaf 
surface  can  break  up  all  the  COj  and  free  all  the  oxygen  in  2500 
litres  of  air, every  hour  of  sunlight. 

Oxygen. — As  already  stated,  the  oxygen  content  of  air  varies 
little  except  in  confined  spaces.  Inspired  air  may  have  an  oxygen 
content  of  20.8  per  cent,  to  20.94  per  cent.,  and  expired  air,  of 
16.0  per  cent.  But  this  expired  air  is  no  more  air,  in  the  usual 
generalized  sense,  than  are  the  gases  one  could  collect  in  a  factory 


AIR  AND  VENTILATION  129 

chimney.  Even  indoors  the  variation  in  oxygen  content  is  sur- 
prisingly small.  In  the  stuffiest  bedroom,  the  most  crowded  class- 
room or  public  hall,  the  difference  in  oxygen  content  ranges  only 
from  30.94  per  cent,  to  20.00  per  cent. 

Experimental  work  with  people  and  other  animals  in  closed 
chambers  has  shown  that  the  oxygen  may  be  reduced  to  17  per  cent. 
or  raised  to  50  per  cent,  without  any  evidence  of  discomfort  or  any 
derangement  of  the  vital  functions.  A  drop  to  11  per  cent,  is 
dangerous,  and  a  reduction  to  7  per  cent,  causes  death;  but  since 
these  low  amounts  are  not  approached  under  ordinary  conditions,  it 
is  easily  seen  that  the  oxygen  content  of  ordinary  air  is  not  an  im- 
portant hygienic  factor. 

This  does  not  imply  that  oxygen  is  not  important  in  the  human 
tody;  it  merely  means  that,  fortunately,  the  oxygen  content  of 
our  environment  is  not  ordinarily  a  matter  requiring  conscious 
adjustment. 

The  average  person  breathes  in  daily  34  pounds  of  air,  or  7 
pounds  of  oxygen,  of  which  but  2.0  pound  is  absorbed. 

In  the  blood,  this  absorbed  oxygen  is  held  both  as  oxygen  and 
as  a  compound  with  haemoglobin  (G).  About  \^  is  held  in  the 
red  corpuscles  (as  a  chemical  compound,  oxyhsemoglobin),  and 
about  "2^  is  held  physically,  in  solution  in  the  liquid  part  of  the 
blood  or  plasma.  As  the  plasma  gives  up  oxygen  to  the  cells,  it 
draws  upon  the  oxygen  in  the  red  corpuscles;  the  red  corpuscles 
regaining  their  full  storage  content  on  their  return  to  the  lungs. 

Ozone. — Ozone,  composed  of  oxygen  only,  has  a  different  group- 
ing of  its  atoms,  three  being  required  to  make  a  molecule  (O3).  It 
is  popularly  spoken  of  as  a  synonym  for  oxygen :  e.g.,  "  to  fill  one's 
lungs  with  ozone,"  and  "where  the  air  is  pure  ozone."  But  it  is 
not  the  same  as  the  gas  (O2)  we  have  just  been  discussing.  The 
different  grouping  of  the  atoms  apparently  makes  it  a  more  un- 
stable substance,  and  it  is  a  very  active  oxidizing  agent;  even 
minute  amounts  {e.g.,  one  part  to  a  million)  are  very  irritating  to 
mucous  membranes,  while  larger  amounts  {e.g.,  15  to  20  parts  pet 
million)  are  fatal  to  human  beings,  lessening  the  oxygen  intake 
and  the  CO2  eliminated,  producing  headache,  drowsiness,  depres- 
sion, and  finally,  unconsciousness  and  death.  Though  traces  are 
normally  present  in  air,  it  is  generally  lacking  in  the  air  of  in- 
habited rooms,  and  occupied  districts  (large  towns) ;  it  is  most 
9 


130  HOME  AND  COMMUNITY  HYGIENE 

abundant  in  forested  regions,  and  at  the  seashore.  Ozone  is  pro- 
duced by  natural  electrical  discharges  (lightning),  by  the  oxida- 
tion of  phosphorescent  substances,  by  the  friction  of  the  ocean  sur- 
faces against  the  air,  and  probably  by  the  activity  of  green  plants. 
As  found  in  air,  it  is  not  a  valuable  disinfecting  agent,  for  it 
rarely  exists  in  air  in  more  than  1  or  II/2  parts  to  a  million,  and 
bacteria  are  not  killed  until  the  amount  equals  13  parts  per  mil- 
lion— a  concentration  injurious  to  man.  Ozone  is  sometimes  manu- 
factured chemically  and  used  to  disinfect  or  to  sterilize  such  sub- 
stances as  drinking  water  and  dressings,  but  that  is  entirely  apart 
from  its  value  as  an  air  constituent. 

Hydrogen  Peroxide. — Hydrogen  peroxide  (HgOg)  is  present 
in  very  small  amounts  in  air,  and  may  be  demonstrated  in  rain- 
water and  snow.  It  is  an  active  oxidizing  agent,  hecause  of  the 
extra  unstable  0  atom;  but,  in  ordinary  air,  is  probably  not  pres- 
ent in  large  enough  amounts  to  have  any  real  value. 

Carbon  Dioxide. — Carbon  dioxide  (CO2)  is  still  popularly 
considered  as  the  one  constant  attribute  of  '^bad  air,'^  although  it 
is  unimportant  even  in  vitiated  air.  Carbon  dioxide  is  present  in 
all  air  in  relatively  small  amounts,  3  parts  to  10,000  or  0.03  per 
cent.  In  smoky  air  (which  delays  its  diffusion)  it  may  rise  to 
0.8  per  cent. ;  in  commercial  processes  it  often  reaches  0.5  to  0.7 
per  cent. ;  a  strikingly  high  percentage  is  formed  in  active  fermen- 
tative processes,  as  in  breweries,  where  10  per  cent,  may  be 
demonstrated. 

Evidences  of  its  unfavorable  effect  do  not  begin  until  5  per 
cent,  has  been  reached,  when  the  breathing  may  be  rapid  enough  to 
be  termed  "  panting  " ;  with  still  increased  amounts,  the  discomfort 
increases  (headache,  nausea),  but  30  per  cent,  may  be  reached  with- 
out loss  of  life,  death  occurring  when  the  percentage  reaches  35  to 
50  per  cent.  Expired  air  contains  4.4  per  cent.  COg.  Our  average 
CO2  output  is  0.4  to  0.6  cubic  foot  per  hour,  increasing  with  ordi- 
nary physical  activity  to  1.0  cubic  foot.  This  sounds  as  if  the 
oxygen  would  soon  be  used  up,  and  as  if  the  CO2  accumulation 
would  rapidly  become  very  great.  But  we  must  recall  that  the  total 
amount  of  atmosphere,  and  the  rapid  diffusion  of  its  gases  make 
such  depletion  and  accumulation  very  unlikely,  even  indoors;  for 
our  houses  are  far  from  being  air-tight  (see  pp.  142  and  143). 

The  blood  coming  back  from  the  tissues  may  have  as  high  as  45 


AIR  AND  VENTILATION  131 

per  cent.  COg.  It  cannot  lose  all  of  its  CO2  in  the  lungs,  for  the 
percentage  of  COg  in  the  blood  cannot  fall  below  that  on  the  air 
side  of  the  alveolar  membranes  (G),  usually  5  to  6I/2  per  cent. 
(See  Osmosis  and  Dialysis  in  Glossary.)  It  may  not  fall  so  low 
in  the  short  time  it  stays  in  the  lungs,  though  the  time  element  is 
not  so  important  as  one  would  think,  because  of  the  immense 
amount  of  alveolar  surface,  recently  estimated  at  over  100  square 
yards.  A  high  percentage  of  CO2  in  the  alveolar  air  will,  therefore, 
limit  or  reduce  the  amount  given  off  to  it  by  the  blood ;  blood  leav- 
ing the  lungs  with  a  high  CO2  content  will  not  be  able  to  remove 
so  much  CO2  from  the  tissues.  Before  this  reaches  a  dangerous 
point,  adjustment  is  made  through  the  respiratory  centre.  A  defi- 
nite amount  of  CO2  is  necessary  to  stimulate  the  respiratory  centre 
(which  is  situated  in  the  medulla  oblongata  (G)  at  the  base  of 
the  brain),  to  keep  up  the  tone  of  the  blood-vessels,  and  to  regulate 
heart  action.  When  the  alveolar  content  exceeds  5  per  cent,  (more 
exactly,  5.3  to  5.7  per  cent.),  the  respiratory  centre  is  stimulated  to 
increased  activity  (deeper  or  more  rapid  breathing,  or  both)  and 
this  better  lung  ventilation  continues  until  the  normal  lower  CO2 
content  in  the  alveoli  is  secured.  The  slight  increases  in  the  CO2 
which  are  ordinarily  met  with  in  the  outside  air  have  little  effect 
upon  the  alveolar  content.  They  are  negligible  compared  with  the 
effects  of  re-breathing  expired  air  (e.g.,  head  almost  covered  by 
bedclothes)  ;  such  expired  air  commonly  contains  about  4%  per 
cent,  of  CO2.  The  respiration  rate  or  depth  is  changed  to  meet 
these  differences,  but  so  readily  and  so  gradually  that  it  is  an  un- 
conscious adjustment.  Even  the  greater  adjustments  necessary  to 
meet  the  accumulating  CO2  from  burning  gas  jets  (3  cubic  feet 
per  hour),  lamps,  and  stoves  may  be  made  without  noticeable 
effort. 

Exercise  increases  the  amount  of  CO2  formed  in  the  body  and 
carried  to  the  lungs ;  this  affects  the  amount  of  CO2  in  the  alveoli, 
and,  as  shown  in  the  preceding  paragraph,  leads  to  compensatory 
changes  in  the  respiration  and  circulation  rates,  continuing  until 
the  former  normal  5  per  cent.  CO2  content  of  alveolar  air  is  estab- 
lished. Lessened  activity  or  sleep  means  that  less  COj  is  formed  in 
the  tissues.  When,  therefore,  the  amount  in  the  blood  and  the 
amount  in  the  alveoli  fall  below  the  normal  5  per  cent.,  respiration 
is  slowed  until  the  normal  amount  again  exists  in  alveolar  air.    In 


132  HOME  AND  COMMUNITY  HYGIENE 

extreme  and,  fortunately,  unusual  cases,  respiration  may  entirely 
cease  for  lack  of  CO2,  and  it  may  be  necessary  to  blow  CO2  into  the 
lijngs  to  start  respiration.  We  are  so  accustomed  to  thinking  of 
oxygen  as  the  only  essential  gas  in  respiration,  and  have  heard  so 
often  of  oxygen  as  a  reviving  agent  where  respiration  is  slowed  or 
difficult,  that  this,  to  some,  seems  almost  unbelievable. 

CO2  Not  an  Index. — As  COg  increases  in  amount  in  occupied 
rooms,  there  is  also  an  increase  in  temperature  and  humidity.  When 
investigators  proved  that  CO2  was  itself  not  an  important  factor  in 
ventilation,  it  was  still  thought  that  the  COg  present  might  serve  as 
an  index  of  air  vitiation.  But  CO2  does  not  accumulate  in  a  room 
in  direct  ratio  with  either  heat  or  humidity,  and  cannot,  therefore, 
be  used  as  a  determining  factor  in  ventilation. 

Carbon  Monoxide. — The  deadly  carbon  monoxide — dangerous 
at  0.2  per  cent,  and  fatal  at  0.4  per  cent. — ^is  sometimes  confused 
with  carbon  dioxide.  Carbon  monoxide  (CO)  has  but  half  the 
oxygen  present  in  carbon  dioxide,  and  is  formed  by  the  incomplete 
combustion  of  coal,  charcoal,  oils,  wood,  and  fuel  gases.  It  is  usu- 
ally, therefore,  a  problem  of  indoor  air.  Usually  such  incomplete 
products  from  coal  stoves  and  grates  make  their  escape  unnoticed  by 
direct  draft  through  the  chimney  or  by  gradual  diffusion  through 
cracks,  windows,  etc.  In  winter,  when  more  fuel  is  used  and  when 
the  aeration  of  the  room  is  less  complete,  cases  of  poisoning  by  this 
gas  are  more  numerous.  Night  fires  are  most  dangerous,  partly  be- 
cause large  amounts  of  coal  are  put  on  at  one  time  (to  last  through 
the  night),  and  partly  because  the  chimney  drafts  are  shut  off  (to 
slow  the  fire). 

Carbon  monoxide  is  found  in  illuminating  gas,  in  amounts 
varying  from  6  to  10  per  cent,  in  coal  gas  to  30  per  cent,  in  water 
gas.  (The  amount  of  CO  in  illuminating  gas  is  limited  by  law  in 
some  States  to  10  per  cent.)  Leaky  gas  fixtures  may  cause  death; 
more  often  they  cause  sleep  disturbances,  such  as  repeated  night- 
mares and  hallucinations,  and  several  "  haunted  houses  "  have  re- 
gained their  good  reputation  when  the  gas  pipes  were  thoroughly 
repaired.  Incomplete  ventilation  or  aeration  of  rooms  where  large 
amounts  of  gas  are  used  for  water  heaters  or  for  room  heating  may 
cause  large  amounts  of  the  CO  in  the  gas  to  escape  in  that  form. 
Long-used  or  uncleaned  burners,  bearing  a  charcoal  crust,  may 
form  CO  in  sufficient  amounts  to  cause  illness  or  death.     The  ex- 


AIR  AND  VENTILATION  133 

haust  of  gas  engines  contains  CO  gas;  and  not  infrequently  the 
running  of  pumping,  threshing  or  automobile  engines  in  closed 
garages  or  buildings  has  caused  death. 

Carbon  monoxide  has  such  a  high  death  rate  for  four  reasons : 
First,  its  presence  is  usually  unsuspected,  as  it  is  practically  odor- 
less. Second,  it  is  injurious  because,  like  CO2,  it  represents  tied-up 
oxygen  which  the  tissues  cannot  use.  Third,  because  carbon  mon- 
oxide makes  a  stable  combination  with  the  haemoglobin  in  the  red 
corpuscles  (carboxy-hsemoglobin)  which  prevents  the  red  corpuscles 
(or  hasmoglobin)  from  giving  their  oxygen  to  the  tissues  and  from 
gaining  more  oxygen  from  the  lungs.  Fourth,  carbon  monoxide  has 
the  power  of  injuring  certain  cells,  such  as  the  nerve  cells,  thus 
causing  paralysis  of  motor  and  respiratory  systems  and  sometimes 
making  it  impossible  even  for  those  still  conscious  to  escape  from 
the  presence  of  the  gas. 

Sewer  Gas. — Sewer  gas  may  have  in  it  leakage  from  illuminat- 
ing gas  pipes,  but  the  gases  which  cause  explosions  in  dead  ends  or 
at  manholes  are  more  often  due  to  gasoline  accumulations  from 
cleaning  establishments,  garages,  or  from  the  oily  streets.  In  most 
places,  it  is  illegal  to  allow  gasoline  from  garages  and  cleaning 
establishments  to  enter  the  sewers  (see  p.  241  for  plumbing  arrange- 
ments to  control  sewer  gas). 

Other  Chemical  Substances  Presisnt  in  Air. — Other  chemical 
substances,  e.g.,  hydrogen  sulphide  and  hydrochloric  acid,  some- 
times exist  in  the  air  as  vapors.  While  usually  relatively  unimpor- 
tant, in  manufacturing  cities  smoke  or  fog  may  hold  such  sub- 
stances near  the  earth  and  make  the  atmosphere  very  irritating  to 
mucous  membranes.  (Singers  often  complain  if  asked  to  include 
certain  towns  in  their  tours,  and  sometimes  find  a  prolonged  stay 
in  such  cities  very  injurious.)  The  chemicals  mentioned  and 
others,  such  as  nitric  and  sulphuric  acids,  formed  mainly  by  the 
burning  of  coal  or  in  industrial  processes,  are  usually  found  in  small 
amounts  (often  less  than  1  part  to  10,000).  These,  as  well  as  CO2, 
are  washed  out  of  the  air  by  rainwater  or  snow,  finally  reach  the 
earth,  and  aid  in  certain,  of  the  soil  changes  {e.g.,  disintegrating 
rock  substances,  forming  mineral  salts  which  are  absorbed  by  roots). 
An  attempt  to  emphasize  the  value  of  these  processes  is  responsible 
for  the  expression,  "  Snow  is  the  poor  man's  manure.^'  Ammonia, 
formed  in  the  decomposition  of  organic  substances,  is  often  produced 


134  HOME  AND  COMMUNITY  HYGIENE 

in  noticeable  amounts  (e.g.,  in  stables).  The  amounts  of  such  sub- 
stances (e.g.,  albuminoid  ammonia)  are  sometimes  used  as  a  test  for 
OBganic  impurities  in  the  air. 

Nitrogen. — No  mention  has  been  made  of  nitrogen,  which 
comprises  four-fifths  of  the  air.  Its  great  value  is  as  a  diluting 
substance.  The  injurious  effect  of  ozone  is  due  to  its  more  rapid 
oxidizing  powers;  it  is,  therefore,  an  advantage  to  have  oxygen 
diluted  to  1/5  of  its  possible  power  by  inert  nitrogen.  Neither  in- 
creased oxidation  in  the  tissues,  nor  increased  combustion  of  fuels, 
is  desirable  for  our  bodies  as  things  are  now  constituted  on  this 
earth.  Nitrogen  does  not  vary  appreciably  in  inspired  and  expired 
air.  It  is  found  in  solution  in  small  amounts  in  the  blood,  though 
larger  amounts  are  absorbed  in  caisson  disease   (see  p.  138). 

Crowd  Poisons. — Expired  poisons,  "  crowd  poisons,^'  have  been 
thought  to  explain  the  discomfort  experienced  in  unventilated 
places,  such  as  the  Black  Hole  of  Calcutta.  Much  experimental 
work  has  been  done:  causing  animals  to  breathe  expired  air,  and 
injecting  washings  of  expired  air  into  animals.  Some  of  the  early 
results  have  been  interpreted  as  supporting  the  existence  of  ex- 
pired poisons,  but  most  of  the  work  fails  to  prove  the  presence  of 
such  substances. 

Odors. — We  all  know,  however,  that  odors  accumulate  in  occu- 
pied rooms.  Odors  often  noticed  in  the  breath  (from  decaying 
teeth,  digestive  disturbances),  from  the  skin  (surface  substances: 
dirt,  perspiration,  and  odoriferous  glands),  from  the  clothing 
(moist  wool  and  fur),  especially  soiled  underclothing,  largely 
account  for  this.  Certain  excretory  glands  (e.  g.,  armpits)  are  more 
active  and  more  odoriferous  in  certain  individuals;  certain  races 
have  characteristically  strong  odors.  These  may  affect  us  unpleas- 
antly, and  though  no  direct  effects  have  been  ascribed  to  them, 
they  are  most  undesirable  for  aesthetic  and  psychological  reasons. 
Absolute  body  cleanliness  is  usually  necessary  to  avoid  such  odors. 
A  few  individuals  may  find  it  advisable  to  reinforce  this  with  some 
preparation  for  absorbing  odors;  but  there  is  no  excuse  or  reason 
for  covering  objectionable  odors  by  perfumes  and  scented  toilet 
powders.  No  one  cares  to  be  summed  up  in  the  phrase,  "  Perfume 
instead  of  soap." 

Although  the  nose  is  usually  an  unreliable  sanitary  guide,  some 
people  seem  to  be  sensitive  to  accumulations  of  expired  CO 2,  and 


AIR  AND  VENTILATION  135 

air  containing  twice  the  usual  amount  of  COg  (0.06  per  cent.)  is 
described  as  "  stuffy  " ;  distinctly  unpleasant  odors  may  be  noticed 
with  higher  amounts  of  COj.  This  effect  has  been  related  to  the 
loss  of  appetite  shown  by  subjects  confined  in  experimental  cham- 
bers. It  may  not  be  necessary  to  think  of  these  accumulations  as 
"  affecting  the  nerves  of  taste  "  directly ;  such  results  may  be  due  to 
slight  and  unrecognized  forms  of  nausea,  as  nausea  is,  in  some,  a 
characteristic  reaction  to  objectionable  odors.  (Habit,  too,  has  long 
associated  physical  discomfort  with  decreased  physical  action  and 
lessened  food  intake,  and  may  explain  decreased  food  intake  in  such 
experiments  without  recourse  to  special  sense  effects,  as  on  the  taste 
nerve  endings.) 

Dust  in  Air. — Dust  particles  increase  the  possible  bacterial 
content  of  air,  dust  or  lint  acting  as  floaters  or  buoys  for  the  bac- 
teria. Dust  itself  may  be  very  injurious,  depending  both  upon 
the  kind  and  upon  the  amount  of  dust  in  the  air.  Fibre  or  min- 
eral dust,  absorbed  constantly  or  in  large  quantities,  may  cause  irri- 
tation and  even  inflammation  of  the  throat  and  lung  membranes, 
causing  chronic  bronchitis  or  phthisis  (see  Industrial  and  Occu- 
pational diseases,  Chapter  XX,  p.  316).  Some  forms  of  dust  (e.  g., 
carbon)  favor  the  formation  of  fog  and  tend  to  keep  a  definite  fog 
or  "  chemical  pall "  over  manufacturing  and  mining  towns.  Such 
fog  and  smoke  are  definitely  irritating  to  respiratory  membranes, 
and  by  such  irritation  may  predispose  to  respiratory  diseases,  as 
they  decrease  the  window  ventilation  of  the  ovemeat  housewife,  and 
decrease  the  actual  amount  of  sunlight  that  can  penetrate  the  atmos- 
phere. Modern  methods  of  cleaning  (vacuum  cleaners,  moist  dust- 
cloths)  are  now  preferred  by  all  intelligent  housewives.  Street  dust 
is,  however,  responsible  for  much  of  our  house  dust;  smoke  from 
chimneys,  dust  from  ash  cans  and  carts,  grit  ground  off  the  paving 
stones  and  asphalt,  and  dust  from  the  roads,  are  constantly  finding 
their  way  houseward  {e.g.,  on  clothing,  through  windows).  Oiled 
streets  and  other  methods  of  reducing  the  street  dust  would  simplify 
greatly  the  housekeeper's  problems. 

Relation  of  Atmosphere  to  Light  and  Heat. — The  effects  of 
the  atmosphere,  though  unrealized  by  us,  are,  nevertheless,  most 
important;  and  though  usually  beyond  our  control,  it  is  interesting 
to  know  what  they  are.  The  air  itself  (water  vapor  also,  and 
more  markedly,  dust  particles)  limits  the  penetration  of  the  sun'a 


136  HOME  AND  COMMUNITY  HYGIENE 

light  and  heat.     Our  colored  sunsets,  the  morning  glow,  and  even 
the  blue  of  the  sky,  are  illustrations  ^  of  this. 

.More  important  from  a  hygienic  standpoint  are  the  following 
effects  of  this  limitation  of  the  penetrating  powers  of  light  and 
heat.  It  makes  our  daylight  less  brilliant  and  less  unbearable  in 
midsummer;  the  bactericidal  effect  of  sunlight  is  reduced;  our 
heated  periods  (days,  summers)  are  less  intensely  hot,  and  we  re- 
ceive correspondingly  less  heat  in  winter.  But  while  the  atmosphere 
keeps  some  heat  out,  it  also  tends  to  lessen  the  rate  at  which  the 
earth  radiates  heat,  thus  "holding  the  heat  in."  Our  earth  tem- 
peratures are  more  uniform;  the  nights  are  not  so  cool  as  they 
would  be  had  we  no  atmosphere,  and  the  winters  are  also  less  cold 
because  of  this  retained  heat. 

Atmospheric  Pressure. — We  are  wholly  unconscious  of  the 
weight  of  the  atmosphere,  even  though  it  exerts  a  pressure  of  fifteen 
pounds  upon  every  square  inch  of  our  body.  Though  the  body 
tissues  are  attuned  to  this,  we  can  vary  this  pressure  considerably 
by  going  deep  down  into  mine  shafts  or  to  the  tops  of  high  moun- 
tains without  being  conscious  of  any  change  in  pressure.  Great 
extremes,  however,  cannot  be  met  easily  and  man  can  stay  but  a 
short  time  at  great  depths;  animals  brought  from  the  depths  of 
the  ocean  cannot  live  at  sea  level.  This  is  partly  due  to  the  in- 
ability of  the  tissues  to  meet  the  new  pressure  conditions.  Such 
inequalities  in  pressure  may  be  illustrated  by  the  ear  pains  noticed 
by  many  people  in  passing  through  under-river  tunnels,  when,  in 
trains,  one  passes  so  quickly  to  a  depth  with  greater  pressure  that 
the  air  in  the  inner  ear  remains  rarer  than  the  air  pressing  against 
the  ear  drum  from  the  outside.     The  drum  is  pushed  in  and  we 

*  Ordinary  white  light  can  be  broken  up  into  seven  prismatic  colors: 
violet,  indigo,  blue,  green,  yellow,^  orange,  and  red.  The  red  rays  are 
stronger  than  the  orange  rays,  the  orange,  than  the  yellow,  and  so  on  to 
the  weak  blue  and  violet  rays.  Under  ordinary  conditions,  more  of  iihe 
stronger  (e.g.,  red  and  yellow)  rays  get  through  the  fifty  or  more  miles 
of  air  enveloping  our  earth.  Therefore,  ordinary  sunlight  is  more  yellow 
than  white.  The  weaker  blue  rays  are  so  held  back  by  the  air  envelope 
that  as  we  look  up  far  into  its  depths,  we  see  those  blue  rays  as<  a  blue 
sky.  The  sunset  and  even  sunrises  seen  over  dusty  cities  are  usually 
brilliant,  orange,  gold,  or  red  predominating,  for  only  the  stronger  rays 
get  through  the  dust-filled  air  to  us.  After  volcanic  outbursts  red  skies 
or  sunsets  (due  to  the  fine  dust)  may  be  noted  often  for  months,  and  even 
on  distant  continents.  See  "Nature  For  Its  Own  Sake,"  by  John  Van 
Dyke,  if  interested  in  this  side  of  air  and  light. 


AIR  AND  VENTILATION  137 

become  conscious  of  "  fullness  "  or  pain.  Swallowing,  or  even  talk- 
ing, may  prevent  one  from  feeling  this  phenomenon,  for  then  the 
denser  tunnel  air  passes  through  the  mouth  and  the  Eustachian  tube 
into  the  ear;  pain  ceases  where  there  is  no  longer  any  difference  in 
pressure  on  the  two  sides  of  the  ear  drum. 

Effects  of  Pressure  on  Gases  in  Blood. — The  effects  com- 
monly discussed  under  pressure  are,  however,  of  another  type. 
They  are  due  to  the  fact  that  gases  are  held  in  solution  in  amounts 
varying  with  atmospheric  pressure.  (Different  gases  have,  of 
course,  different  initial  rates  of  solubility,  e.g.,  carbon  dioxide  is 
more  soluble  in  water  than  oxygen,  and  oxygen  more  soluble  than 
nitrogen.) 

Therefore  the  amounts  of  oxygen,  carbon  dioxide,  and  even 
nitrogen  in  solution  in  the  body  liquids  (lymph  and  blood)  vary 
with  the  altitude.  The  adjustments  necessary  to  meet  any  increase 
or  decrease  in  oxygen,  for  example,  are  made  so  promptly  and  so 
mechanically  that  we  are  often  wholly  unconscious  that  respiration 
and  circulation  have  been  modified  at  all.  At  great  heights  the  air 
is  very  rarefied  and  the  pressure  is  much  less.  The  amount  of  oxy- 
gen held  in  the  blood  is  reduced.  In  other  words,  a  given  amount 
of  blood  cannot  then  carry  or  hold  its  usual  amount  of  oxygen.  If 
the  tissues  are  to  have  their  usual  amount  of  oxygen,  more  blood 
must  be  sent  through  those  tissues  in  a  given  time;  therefore,  the 
blood  must  circulate  more  rapidly.  A  quickened  circulation  and 
increased  respiration  (depth  or  rate  or  both)  are  the  main  com- 
pensatory changes  noticed  at  high  altitudes.  (There  are  other 
changes;  e.g.,  the  increased  evaporation  of  water  from  the  skin 
means  lessened  kidney  excretion,  and  the  heat  loss  due  to  this  in- 
creased skin  evaporation  may  call  forth  the  compensatory  changes 
already  discussed  under  temperature.)  Unless  these  changes  fully 
compensate  for  the  decreased  gas  tensions  in  the  blood  (its  lessened 
power  to  hold  oxygen  and  also  carbon  dioxide  in  solution),  the 
tissues  will  receive  less  oxygen  from  the  blood,  and  the  blood  will 
takes  less  CO2  from  the  tissues.  Drowsiness  and  finally  unconscious- 
ness are  common  results  shown  at  high  altitudes.  The  compensatory 
work  demanded  by  the  altitude  may  exceed  the  power  of  the  re- 
spiratory and  circulatory  systems.  The  condition  of  the  lungs  and 
heart  is,  therefore,  an  important  part  of  the  physical  examination 
required  of  army  aviators.     The  highest  altitudes  at  which  con- 


138  HOME  AND  COMMUNITY  HYGIENE 

tinued  residence  is  known  is  5880  metres  (or  19,290  feet) ;  at  this 
height  the  atmospheric  pressure  is  but  less  than  half  of  the  pres- 
sure at  sea  level.  Temporary  altitudes  of  7925  metres  (or  26,000 
feet)  and  probably  9000  metres  (or  29,550  feet)  have  been  recorded 
for  aviators.  Some  idea  of  the  body  adjustments  required  by  such 
altitudes  may  be  gained  from  the  following  figures : 

Pressure  (mercury) 
Altitude  barometer  Oxygen  pressure  Per  cent.  Oxygen 

0  or  sea  level. .  760  mm.  100  per  cent,  (or  normal)  20.  per  cent. 
8050  meters    . .   251  mm.  52  per  cent.  6.8  per  cent. 

It  has  been  claimed  that  compensation  for  reduced  oxygen  pres- 
sure is  made  by  increasing  the  number  of  red  corpuscles.  The  in- 
creases described  have  apparently  been  more  rapid  than  their  method 
of  formation  would  allow.  A  slight  increase  in  the  number  of  red 
corpuscles  in  a  given  bulk  of  blood  may  be  found,  because  the 
evaporation  of  water  from  the  body  is  more  rapid  at  high  altitudes, 
and  there  would  be  a  slight  decrease  in  the  total  bulk  of  the  blood 
in  the  body  and  a  slight  increase  in  the  concentration  of  the  blood. 
But  it  is  thought  that  the  claimed  increase  in  the  number  of 
corpuscles  is  mainly  explained  by  the  difficulties  attending  the  mak- 
ing of  the  blood  counts  (G)  at  high  altitudes.  The  samples  of  blood, 
exposed  to  the  air  during  this  process,  lose  water  very  rapidly,  and 
the  unit  placed  on  the  slide  for  counting  is,  therefore,  a  concen- 
trated liquid  yielding  a  higher  red  corpuscle  count. 

Increased  Pressure. — Below  sea  level,  the  pressure  increases 
rapidly.  Ten  metres  (thirty-three  feet)  means  twice  the  pressure; 
thirty  metres  (about  one  humdred  feet)  below  sea  level  the  pres- 
sure is  increased  four  times,  and  equals  sixty  pounds  per  square 
inch.  There  is  an  increase  in  the  gases  held  by  the  blood,  and  even 
nitrogen  may  be  absorbed  by  the  blood  in  appreciable  amounts.  The 
results  of  greatly  increased  pressure  are,  as  would  be  expected,  the 
opposite  of  those  experienced  with  decreased  pressure  at  high  alti- 
tudes. The  respiration  and  the  circulation  are  slowed ;  the  evapo- 
ration of  water  is  decreased;  headache,  dizziness,  and  acute  pain 
may  be  experienced  until  the  pressure  inside  the  body  becomes  equal 
to  the  outside  pressure.  Deep  sea  divers  were  formerly  our  common 
illustration,  but  the  present  method  of  building  under-river  tunnels 
by  increasing  the  air  pressure  in  a  given  structure  or  caisson  suffi- 
ciently to  keep  water  and  mud  out  is  more  familiar  to  most  of  us. 


AIR  AND  VENTILATION  139 

The  atmospheric  pressure  in  such  cases  is  rarely  more  than  four 
timesi  the  sea  level  pressure  (sixty  pounds  per  square  inch).  A  re- 
turn to  normal  pressure  is  often  accompanied  or  followed  by  intense 
suffering  (pain,  paralysis,  etc.,  called  "  bends,"  "caisson  disease  "). 
The  gases  held  in  solution  diminish  in  the  body  liquids  as  the 
normal  pressures  are  reached ;  and  often  form  "  gasi  emboli "  or 
bubbles,  especially  when  the  change  from  great  pressure  to  normal 
pressure  is  made  too  rapidly.  Oxygen  and  carbon  dioxide  are  more 
easily  absorbed  by  the  Blood ;  that  is  one  reason  why  emboli  are  less 
often  due  to  them  than  to  nitrogen.  These  gas  bubbles  or  emboli 
may  interfere  with  the  circulation  by  clogging  a  capillary  or  rup- 
turing the  capillaries,  causing  serious  internal  hemorrhages;  or 
death  may  follow  from  the  pressure  exerted  by  these  bubbles  in 
dangerous  areas,  such  as  the  brain  and  spinal  cord. 

Ventilation. — ^Ventilation — a  word  of  varied  meanings — ^usu- 
ally implies  a  replacement  of  used  air  by  fresh  unused  air.  Always 
would  seem  the  natural  word  to  use  here  instead  of  usually,  except 
that,  recently,  used  air  has  been  washed  and  used  over  again.  The 
replacement  of  used  air  (whether  constant  or  periodic)  must  be 
rapid  enough  to  prevent  the  accumulation  of  odors,  heat,  humidity, 
factory  dust,  etc.,  in  objectionable  amounts.  Adequate  replacement 
is  usually  implied  in  the  term;  for  example,  we  speak  of  certain 
rooms  as  being  poorly  ventilated  when  the  air  replacement  is  so 
slow  that  we  become  conscious  of  the  accumulated  odors,  moisture, 
etc.    (See  also  ventilation  and  heating  in  Chap.  XIII.) 

Ventilation  is  a  cold-weather  problem,  and  when  we  speak  of  a 
good  ventilating  system,  or  of  a  room  or  building  as  well-ventilated, 
we  mean  more  than  an  adequate  replacement  of  air — bulk  for  bulk. 
We  mean  that  the  fresh  air  is  supplied  without  noticeable  drafts 
and  without  periods  of  unpleasantly  low  temperature.  Where  the 
subtraction  of  used  air  and  the  addition  of  fresh  air  are  made  gradu- 
ally in  small  amounts,  these  difficulties  are  less  often  met.  When 
the  fresh  air  is  taken  directly  from  outdoors,  both  may  be  noticed, 
unless  the  fresh  air  enters  through  specially  contrived  openings 
(1)  directing  the  entering  air  away  from  the  occupants  of  the 
room  or  (2)  forcing  it  through  finely  meshed  screens.  Cold  outer 
air  is  often  heated  by  radiators  placed  directly  under  the  windows, 
thus  avoiding  chilly  drafts.  Used  air  becomes  both  warmer  and 
moister   (lighter)  ;  therefore,  vents  for  used  air  are  often  placed 


140 


HOME  AND  COMMUNITY  HYGIENE 


near  the  top  of  the  room,  often  opening  into  the  chimney,  the  draft 
in  the  chimney  favoring  the  upward  passage  of  the  heated  used  air. 
Thete  are  advantages,  however,  in  having  the  heated  air  come  in 
near  the  upper  part  of  the  room,  as  shown  by  the  following  illus- 
trations, showing  how  much  more  completely  the  fresh  air  diffuses 
through  the  room  (Figs.  33  and  34).  By  pumps,  fans,  etc.,  other 
methods  of  intake  and  outgo  may  be  used,  and  the  used  air  may 
often  be  drawn  out  at  the  bottom  of  the  room.     Special  ducts  for 


Fig.  33. — Formerly  it  was  more  common  in  special  heating  systems  to  have  the  warm 
air  come  in  at  the  bottom.  In  such  systems  why  is  it  not  advisable  to  take  the  used  air  out 
of  the  same  side  of  the  room? 


air  intake  and  outgo  are  found  in  systems  which  are  thrown  out  of 
operation  by  other  openings  or  currents,  and  in  which  the  windows 
must,  therefore,  be  kept  closed.  (This  makes  these  systems  un- 
popular with  most  people:  the  psychological  effect  of  an  open  win- 
dow is  well  known,  whether  the  individual  desires  it  open  or  whether 
he  desires  it  shut.)  The  result  is  that  irregular  or  too  high  tem- 
peratures and  changing  conditions  of  the  occupants  of  the  school  or 
factory  (greater  muscular  activity  or  excitement)  make  the  closed 
windows  seem  unbearable  at  times,  and  here  and  there  windows  are 
opened,  giving  relief  in  the  rooms  concerned,  but  throwing  the 
system  entirely  out  of  operation  for  other  rooms.     These  various 


AIR  AND  VENTILATION 


141 


systems  are  so  different  in  details,  and  so  few  students  taking  only 
elementary  courses  in  hygiene  will  be  called  upon  to  operate  or 
install  complicated  ventilation  systems  that  they  cannot  be  given 
more  space  here.  If  such  responsibility  comes  to  any  individual  he 
should  consult  more  advanced  texts,  studying  the  matter  thor- 
oughly before  making  such  a  momentous  decision — for  a  system 
once  installed  is  very  difficult  to  change,  and  the  original  cost, 
often  enormous,  sometimes  bears  little  relation  to  the  value  of  the 


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Pig.  34._ — If  fresh  heated  air  enters  near  the  top,  it  diffuses  more  gradually  through 
the  room  as  it  cools,  as  shown  by  the  above  illustration.  (There  are  good  systems  in  which 
the  inlets  and  outlets  are  arranged  very  differently,  however.) 

system.  An  indication  of  these  difficulties  is  shown  by  the  fact  that 
some  systems  are  built  upon  erroneous  statements  regarding  the 
weight  of  moist  air,  or  the  relative  amounts  of  water  in  warm  and 
cold  air. 

While  it  is  desirable  that  the  incoming  air  should  not  be  ad- 
mitted at  such  low  temperatures  or  at  such  long  intervals,  and 
therefore  in  such  large  amounts,  that  it  produces  a  noticeable  chill, 
there  may  be  a  distinct  disadvantage  in  the  accurately  controlled 
thermostat  heating.  If  it  is  too  perfectly  regulated,  the  temperature 
is  too  uniform,  and  the  skin  loses  the  opportunities  for  constant  ex- 
ercise as  a  thermal  regulator.  That  is  one  advantage  of  leaving  the 
windows  as  part  of  the  ventilating  system ;  short,  sharp  changes  in 


142 


HOME  AND  COMMUNITY  HYGIENE 


temperature  may  have  a  decidedly  tonic  effect  upon  the  physical  and 
mental  condition  of  the  occupants,  especially  when  they  are  "under 
control  of  other  people,  occupied  with  monotonous  work,  etc.  Ee- 
cent  studies  of  several  thousand  school  children  showed  fewer  ab- 
sences due  to  any  illness,  and  fewer  cases  of  respiratory  diseases  in 
the  children  occupying  vnndow-ventilated  rooms  than  for  children 
occupying  rooms  mechanically  ventilated  (p.  261). 


Fig.  35. — This  indicates  how  much  cracks  and  fireplace  help  in  ventilation. 


Natural  Ventilation. — Many  of  us  know  homes  and  other 
buildings  where  ventilation  is  a  matter  of  little  concern,  and  jet 
the  air  is  not  noticeably  bad,  and  the  occupants  are  apparently  not 
affected  by  such  carelessness.  Fortunatel}',  a  considerable  exchange 
of  indoor  air  and  outdoor  air  is  accompanied  by  the  opening  of 
doors  as  the  various  members  of  the  family  go  about  their  customary 
work  or  play.  The  restless  child,  who  "  won't  stay  in  or  out,"  often 
performs  a  real  service  for  the  home.  Most  buildings  have  enough 
cracks  and  openings  to  afford  a  constant,  though  often  inadequate, 
replacement  of  the  indoor  air  (Fig.  35)  ;  these  include  fireplaces, 
loose  window  sashes,  sagging  doors,  and  unputtied  window  frames. 


AIR  AND  VENTILATION  143 

Storm  doors,  double  windows,  felt  or  metal  weather-strips  delay 
this  replacement,  but  are  popular  because  they  conserve  the  heat. 
If  the  heating  system  allows  any  margin,  and  these  openings 
do  not  cause  objectionable  drafts,  it  is  better  to  omit  such  com- 
mon preparations  for  winter,  unless  sufficient  ventilation  is  pro- 
vided for  otherwise  (air  ducts,  daily  open-window  airing  of 
rooms,  etc.)- 

Air  exchange  is  also  accomplished  through  the  building  ma- 
terials themselves.  A  strong  wind  may  force  large  amounts  of  air 
through  brick,  stone  and  hollow  tile  walls.  This  "  spontaneous  ven- 
tilation "  may  mean  an  interchange  of  several  cubic  feet  per  hour 
for  every  square  yard  of  surface.  This  means  loss  of  indoor  heat, 
so  we  make  our  walls  poorer  conductors  of  heat  and  leiBs  favorable 
to  air  exchanges  by  better  insulated  or  more  numerous  air  spaces; 
e.g.,  by  air  spaces  between  the  lath,  layers  of  tar  or  sheathing  paper 
between  the  framework  and  the  shingles,  and  paint  or  paper  on  the 
inside  walls. 

The  exchange  described  in  the  last  two  paragraphs  may  be  suffi- 
cient to  prevent  discomfort  due  to  the  accumulation  of  gas,  moisture 
and  heat.  They  do  not  always  prevent  the  accumulation  of  odors, 
and  a  definite  effort  to  secure  good  aeration  is  usually  necessary  to 
avoid  "  stuffiness." 

Indoor  air  is  usually  too  dry.  It  probably  always  holds  as  much 
water  per  cubic  foot  as  the  outdoor  air,  and  usually  holds  much 
more.  But  it  can  hold  so  much  more  at  the  higher  indoor  tem- 
peratures that  it  is  often  relatively  very  dry  (as  explained  under 
humidity).  What  it  can  yet  take  up  is  what  really  aifects  us  by 
affecting  the  rate  of  evaporation  of  water  from  our  body  and  the  re- 
sultant loss  of  body  heat.  In  winter  it  is,  therefore,  not  enough  to  add 
warm,' fresh  air;  moisture  must  be  added,  also.  If  rooms  at  20° 
to  21°  C.  (68°  to  70°  F.)  are  not  warm  enough,  it  is  because  the 
air  is  too  dry,  and  the  resultant  evaporation  gives  the  sensation  of 
"  chill "  which  makes  us  demand  more  heat,  when  we  might  more 
economically  secure  comfort  by  adding  moisture  only.  To  most 
people  the  estimates  of  the  water  necessary  to  provide  the  required 
humidity  will  be  startlingly  high.  One  authority  estimates  that  hot 
water  boxes  should  add  15  gallons  per  day  to  the  air  of  an  ordi- 
nary house  (17,000  cubic  feet) ;  another  kept  a  favorable  humidity 
by  evaporating  4I/2  gallons  per  day  in  his  office ;  one  square  foot  of 


144  HOME  AND  COMMUNITY  HYGIENE 

water  surface  per  ordinary  house  room  (10  X  14  feet)  is  a  third 
estimate;  and  the  Bell  Telephone  Company  in  Boston  evaporates 
1^/^  barrels  of  water  per  hour  for  a  building  containing  450  em- 
ployees, thereby  requiring  "3°  less  heat  for  the  maintenance  of  an 
agreeable  temperature/'  Well-ventilated  rooms,  therefore,  not  only 
have  the  used  air  replaced  by  fresh  air,  but  by  fresh  air  of  suitable 
heat  and  water  content.  The  value  of  moisture  is  not  realized  by 
most  people ;  their  only  concern  seems  to  be  that  the  glued  "  fur- 
niture cracks  apart — steam  (or  furnace)  heat  is  so  drying,  you 
IvQOW  "     (see  p.  229). 

Washed  Air. — In  institutions,  office  buildings,  etc.,  these  needs 
have  led  to  the  installation  of  special  "  systems  "  of  heating  such 
as  washed  air,  whereby  sufficient  renewals  of  warm  air  of  suitable 
humidity  may  be  supplied,  without  waste  in  that  expensive  requisite, 
heat. 

It  can  be  readily  seen  that  there  is  great  economic  waste  in  con- 
tinually heating  and  discarding  thousands  of  cubic  feet  per  person 
every  day.  Washed  air,  which  can  be  returned  to  the  room  with- 
out loss  of  heat,  has  therefore  been  advocated.  The  used  air  is 
washed  by  a  spray  of  water  or  is  forced  through  a  reservoir  of 
water,  and  odors,  most  gases,  dust,  etc.,  are  removed,  COg  is  not 
removed,  but  good  results,  judged  by  physical  and  chemical  tests 
and  by  mental  tests  of  the  room  occupants,  indicate  that  washed  air 
has  real  value.  Some  authorities  claim  that  odors,  too,  are  not 
fully  removed. 

Rate  of  Air  Renewal. — ^The  estimates  of  air  needs  were  for- 
merly based  on  the  CO2  accumulation,  though  now  we  know  that 
temperature,  humidity,  air  movement,  and  foreign  substances  (dust, 
bacteria,  etc.)  are  much  more  important  considerations.  Most 
people  still  accept  2000  to  3000  cubic  feet  per  hour  as  the  average 
need  for  each  individual.  In  small  rooms,  where  the  actual  room 
space  is  less  than  this  minimum,  the  same  result  is  secured  by  re- 
placing the  air  more  rapidly.  The  estimate  varies  with  the  size  of 
the  individual,  the  amount  of  work  or  exercise,  and  what  is  not 
often  realized,  the  shape  of  the  room.  A  room  with  high  ceilings 
may  enclose  a  large  amount  of  air,  but  if  a  great  part  of  that  air 
lies  above  any  wall  opening  {e.g.,  window,  ventilator),  it  is  really  a 
dead  air  space  in  which  the  air  is  affected  very  slightly  by  most 
ventilating  schemes      Most  of  us  know  that  such  ceiling  air  is 


AIR  AND  VENTILATION  145 

warmer,  but  we  fail  to  recognize  that  other  products  of  vitiated  air 
{^e.g.,  odors,  gases,  moisture)  diffuse  so  slowly  that  the  upper  layer 
of  air  is  little  affected  by  the  fresh  air  below.  This  leads  some 
authorities  to  emphasize  the  square  feet  of  floor  space  rather  than 
the  cubic  feet  of  air  space.  Cases  of  fainting  in  outdoor  crowds  are 
not  uncommon  in  warm  weather;  in  such  instances  the  body  accu- 
mulations (heat,  moisture,  odors)  did  not  diffuse  through  the  air — 
even  upward — rapidly  enough  to  prevent  discomfort.  Floor  space 
requirements  range  frDm  10  to  50  square  feet  per  person,  vary- 
ing with  the  cubic  feet  of  air  space  also  obtainable  for  each. 

Cooling  Systems. — Hospitals  and  office  buildings  have  been 
the  pioneers  in  installing  cooling  systems  for  summer.  "  Comfort  " 
is  a  sufficient  excuse,  but  how  much  comfort  adds  to  the  working 
power  of  an  individual  or  to  the  life  chances  of  a  sick  baby,  few  of 
us  realize. 

Schemes  have  been  advanced  for  conserving  summer  heat  for 
winter  heating,  and  for  storing  chilled  air  or  water  in  the  winter 
for  summer  use,  but  few  institutions  or  individuals  have  actually 
installed  cooling  plants,  though  some  advantage  is  taken  of  the 
benefits  derived  from  air  movement  (electric  fans)  and,  less  often, 
from  water  evaporation  (as  described  earlier  in  this  chapter). 
When  health  is  really  recognized  as  the  one  great  asset  of  the  in- 
dividual and  the  nation,  and  when  the  relation  of  physical  comfort 
and  efficiency  is  firmly  established,  we  may  expect  to  find  all  civic 
and  commercial  institutions  fitted  with  cooling  plants  for  summer, 
as  well  as  heating  plants  for  winter.  Eeally  efficient  heating  sys- 
tems are  less  than  eighty  to  ninety  years  old,  and  the  re- 
frigerating systems  have  been  so  perfected  that  we  may  confidently 
expect  some  relief  from  the  intense  summer  heat  within  the  next 
generation. 

Although  complicated  systems  of  ventilation  do  not  belong  in 
an  elementary  book  of  hygiene,  there  are  many  simple  aids  to  ven- 
tilation that  every  one  should  know  about;  for  most  of  us  control 
entirely  the  ventilation  of  one  or  more  rooms,  especially  at  night. 
Two  windows,  especially  if  not  on  the  same  side  of  the  room,  flush  a 
room  much  more  rapidly  than  one  window,  even  when  the  open  area 
is  the  same.  With  one  window,  openings  at  the  top  and  bottom 
are  more  effective  than  but  one  opening  at  the  top  or  bottom ;  even 
with  two  openings  cold  air  may  enter  the  bottom  and  go  directly 
10 


146 


HOME  AND  COMMUNITY  HYGIENE 


out  at  the  top,  affecting  very  slightly  most  of  the  room  air.  A 
board  inserted  below  the  lower  sash  raises  the  top  of  that  sash  suffi- 
cieotly  to  let  in  small  amounts  of  fresh  air  constantly.  Instead  of 
a  board,  screens  with  slanting  (glass)  shields  are  sometimes  used; 
these  give  two  openings  instead  of  one,  and  by  throwing  the  screened 
air  upward,  make  drafts  less  noticeable. 

Sleeping   Porches. — Sleeping  porches  have  two   advantages: 
(1)  They  conserve  heat  otherwise  lost  by  opening  the  windows  at 


Fig.  36. — A  sleeping  hood  fastened  over  a  window  screen  and  fitted  into  a  casement 
window  which  opens  out;  this  hood  is  folded  under  the  mattress  at  the  head  of  the  bed  and 
runs  down  between  the  lower  and  top  blankets. 

night,  and  (2)  they  insure  good  fresh  air  for  eight  or  ten  hours  of 
the  twenty-four.  If  the  sleeper  buries  his  face  beneath  the  bed- 
clothes, even  outdoor  sleeping  does  not  insure  unvitiated  air,  for 
the  bent  neck  or  layers  of  blankets  cause  him  to  re-breathe  the 
same  old  air.  That  animals  (cats,  dogs)  do  so  habitually  or  that 
hibernating  animals  do  so  for  long  periods  (respiration  very  slowed, 
however),  or  that  foreign  nations  have  slept  for  years  in  closed  box 
beds  or  under  feather  beds,  should  not  be  considered  an  argument 
against  fresh  air.     As  strong,  on  the  other  side,  is  the  discomfort 


AIR  AND  VENTILATION  147 

felt  by  fresh-air  peo^ale  when  compelled  to  breathe  vitiated  air. 
And  we  have  all  experienced  the  lassitude,  headache,  loss  of  appe- 
tite due  to  close  and  stuffy  places  (Pullman  coaches,  unventilated 
rooms).  A  still  greater  warning  is  the  anaemic  condition  of  those 
who  habitually  "  shut  themselves  up."  That  air  conditions  have 
much  to  do  with  this  is  indicated  by  the  higher  death  rate  of 
soldiers  in  crowded  barracks  than  in  less  crowded  ones,  even  in 
regiments  where  all  were  selected  by  the  same  general  health  stand- 
ards, and  all  had  the  sam"e  food,  exercises,  etc.  The  beneficial  results 
directly  traced  to  open-air  schools,  open-window  schools,  and  open 
camps  for  the  tubercular  show  that  fresh  air  offers  indisputable 
advantages  for  all  of  us.  Unless  one  can  command  sufficient  bed- 
ding or  can  afford  the  greater  loss  of  energy  represented  in  the 
greater  amount  of  heat  given  off  in  surroundings  colder  than  the 
ordinary  bedroom,  including  the  initial  amount  required  to  warm 
a  thoroughly  chilled  bed,  it  would  be  wiser  to  sleep  indoors.  Any 
ingenious  person  can  "  rig  up  "  a  hood  of  canvas,  old  blankets,  etc., 
which  can  be  fastened  to  an  extra  glassless  sash  (or  tacked  perma- 
nently around  the  lower  half  of  the  window) .  This  can  be  tucked 
over  and  around  the  pillow  and  under  the  mattress,  allowing  plenty 
of  fresh  air  around  the  head,  while  the  body  remains  in  a  warm 
room,  which  is  comfortable  for  both  the  evening  and  morning 
toilets  (Fig.  36).  Of  course,  each  must  carefully  decide  for  him- 
self whether  outdoor  sleeping  is  really  unwise;  too  often  a  sluggish 
skin  or  mere  inertia  is  allowed  to  settle  the  matter. 

PROBLEMS 

1.  How  does  fresh  air  enter  your  schoolroom  in  winter  time?  How 
often  would  the  air  have  to  be  replaced  tO'  give  each  person  the  minimum 
requirement,  2000  cubic  feet  per  hour? 

2.  Explain  why  increased  humidity  makes  hot  days  hotter  and  cold 
days  colder. 

.3.  Explain  the  system  of  ventilation  in  this  building.  Does  it  con- 
tradict any  of  the  accepted  laws  of  physics  (e.g.,  hot  air  rises)  ?  In  a 
large  institution  the  janitor  might  be  asked  to  describe  the  system  to  the 
class.  What  are  the  advantages  to  be  gained  (for  the  student  and  for  the 
school)   by  so  doing? 

4.  How  could  the  ventilation  of  this  room  be  improved  without  chang- 
ing the  system  of  heating  or  ventilation  already  installed? 

.5.  How  much  air  space  per  person  in  this:  schoolroom?  In  the  school 
assembly  room?  How  long  should  students  sit  there  without  opening  the 
windows  or  otherwise  replacing  the  air? 

6.  What  effect  do  winds  have  upon  the  air  of  this  room?  Describe  a 
room  in  which  they  would  have  greater  (or  less)  effect,  and  explain  why. 


148  HOME  AND  COMMUNITY  HYGIENE 

7.  Collect  all  the  facts  you  can  in  favor  of  frequent  exposure  to  out- 
door air ;  errands  outdoors,  short  walks  to  school  or  business,  sleeping  out- 
doors, or  outdoor  schools,  etc. 

J  8.  Does  the  amount  of  water  evaporated  daily  in  your  room  (house) 
during  the  winter  indicate  that  the  humidity  is  sufficiently  high?  Does 
the  temperature  found  necessary  for  comfort  support  this?  Can  you 
secure  a  wet-bulb  thermometer  to  test  this? 

9.  Design  a  sleeping  hood  to  fit  in  the  low^er  part  of  an  ordinary  sash 
window  and  to  cover  the  head  of  your  bed.  Construct  it  upon  a  fly  screen 
or  framework  just  the  size  of  the  lower  sash,  so  that  it  will  fit  snugly  (as 
screens  do)  into  the  space  made  by  raising  the  lower  sash.  How  can  you 
prevent  drafts  or  loss  of  heat  around  the  outside  edges  of  the  hood?  (A 
little  cape  or  a  small  blanket  which  can  be  cut  half  way  across  and  then 
fastened  around  the  neck  makes  a  desirable  addition  to  this  sleeping 
arrangement. ) 

10.  Without  winds  sandstone  and  brick  surfaces  may  pass  four  to 
eight  cubic  feet  of  air  per  hour  in  a  square  yard  of  surface ;  and  winds 
increase  this  amount  many  times.  How  would  this  affect  the  heating  of 
rooms  with  outside  surfaces?     Their  ventilation? 

11.  During  a  storm  200  steerage  passengers  on  the  steamer  London- 
derry were  shut  below  over  night  in  a  space  18  feet  by  17  by  11,  without 
any  ventilation  at  all.  In  the  morning  over  seventy  were  dead.  What 
caused  their  death? 

12.  An  ordinary  fireplace  fire  means  a  movement  of  18,000i  cubic  feet 
per  hour.  How  is  this  amount  of  fresh  air  supplied  to  the  fire  in  your 
house?  At  the  minimum  rate  of  2000  cubic  feet  per  person  per  hour,  will 
this  supply  the  necessary  ventilation  for  your  living  room? 

13.  A  fireplace  fire  demands  2600  culjic  feet  of  moving  air  per  pound 
of  coal  used.  If  you  used  fireplace  heat  and  ventilation  only  in  your  room, 
what  would  adequate  heat  and  fresh  air  cost  you  per  day? 

14.  The  minimal  room  space  is  one-third  of  the  required  cubic  feet  of 
air  necessary  per  hour,  but  hospitals  count  on  full  space  for  ordinary 
patients  and  2.500  for  fever  patients.     Explain  why  this  is  advisable. 

15.  Show  why  an  opening  into  the  chimney  near  the  ceiling  is  usually 
a  good  place  for  the  outgoing  air  vent. 

16.  Theoretically  radiation  is  not  aftected.  by  temperature  or  humidity. 
But  since  every  mass  of  matter,  as  well  as  the  human  body,  radiates  heat, 
our  bodies  are  constantly  receiving  radiated  heat  from  every  object  in  our 
environment,  even  the  tiny  moisture  particles  in  the  air !  Show,  therefore, 
for  a  very  low  temperature  (zero  weather)  or  a  very  hot  temperature  (100° 
in  shade ) ,  that  the  radiation  loss  is  really  a  balance  between  the  heat  lost 
and  received  by  radiation.  Does  this  justify  the  statements  on  p.  120  and 
p.   12.5  regarding  temperature  and  humidity? 

See  Reference  List  at  end  of  Appendix. 


CHAPTER  VII 
SEWAGE  DISPOSAL 

Despite  the  great  complexity  of  the  problem  of  sewage  disposal, 
there  are,  after  all,  but  two  ways  of  disposing  of  sewage :  the  dry- 
earth  system  and  the  water-carriage  system. 

The  Dry-earth  System. — In  this  method  of  sewage  disposal 
dry  earth  is  used  to  cover  the  contents.  This  may  be  done  by  a 
mechanically  adjusted  hopper,  which  automatically  showers  earth 
into  the  vault  below,  or,  more  simply,  by  adding  shovelfuls  of  earth 
from  a  bucket  or  box  kept  in  the  closet.  The  disadvantages  of  this 
method  are  that  it  necessitates  keeping  on  hand,  protected  from  rain 
and  freezing,  a  large  amount  of  earth,  ashes,  etc.,  suitable  for  this 
purpose;  filling  the  hopper  or  bucket  with  fresh  earth  or  ashes  is 
a  daily  chore  at  least,  and  must  be  attended  to  in  all  kinds  of 
weather;  because  of  these  earth  additions  the  bulk  in  the  receiving 
vault  increases  rapidly,  necessitating  frequent  emptying  of  the 
accumulations. 

The  ordinary  privy  should  be  turned  into  a  dry-earth  system. 
Even  then,  flies  will  be  attracted  to  such  places,  and  seat  covers 
that  automatically  close  when  not  in  use  should  be  provided  (Fig. 
37),  and  the  vault  should  be  of  tight  construction  or  completely 
screened  to  prevent  the  entrance  of  rats  and  flies. 

The  Pail  System. — ^The  pail  closet  has  little  to  recommend  it  if 
other  methods  are  possible.  The  pail  should  be  removed  at  least 
daily  and  the  contents  buried.  This  makes  the  pail  closet  really  a 
dry-earth  method.  The  pail  closet  has  all  the  disadvantages  of  the 
dry-earth  closet  plus  the  disadvantage  of  splashing  and  the  more 
unpleasant  task  of  emptying  and  properly  cleaning  the  pail. 
Splashers  in  or  above  the  containers  are  impossible  to  keep  clean, 
though  the  slight  fall  in  such  closets  makes  such  a  device  desirable. 
The  person  upon  whom  the  task  of  emptying  and  cleaning  the  con- 
tainers is  forced  is  usually  more  concerned  in  doing  it  the  quickest 
way  than  in  doing  it  the  right  way.  Burial  demands  a  larger  area 
for  receiving  such  material  than  is  usually  obtainable.  Pail-closets 
should  not  be  constructed  unless  care  can  be  assured. 

149 


150 


HOME  AND  COMMUNITY  HYGIENE 


Wherever  possible,  the  dry-earth  methods  should  he  supplanted 
by  water-carriage  systems.  Warren  has  studied  this  question  from 
the  point  of  view  of  land  valuations  in  the  city  and  country,  the  real 


Fig.  37. — Pail  and  seat  details  of  a  sanitary  pail  closet. 

ccstto  the  cities  (assessments,  indirect  taxes,  etc.),  and  decides  that 
the  cheaper  construction  possible  in  the  country  makes  water- 
carried  plumbing  just  as  possible  for  the  rural  districts  as  for  the 
towns  and  cities. 


SEWAGE  DISPOSAL  151 

Introduction  of  Water-Carriage  Systems. — The  water-car- 
riage system  is  relatively  new.  Harrington  pictures  a  curious  water- 
flushed  closet  in  use  in  England  in  1596;,  but  water-flushed  closets 
did  not  come  into  common  use  until  a  relatively  short  time  ago. 
Until  recently  it  was  forbidden  to  empty  any  house  drainage  into 
the  sewers.  London  did  not  allow  it  before  1815 ;  Boston,  1833 ; 
and  Paris  not  until  1880.  Once  introduced,  water  closets  rapidly 
supplanted  more  primitive  devices.  London,  in  1847,  required 
water  closets  to  be  connected  with  the  sewers ;  Chicago  began  a 
water-carriage  system  in  1855,  and  Boston  in  1875.  Many  of  our 
cities  were  much  slower ;  Baltimore  is  only  just  completing  a  com- 
plete sewerage  system. 

Processes  Important  in  Sewage  Disposal. — Water-carriage 
methods  always  seem  very  complicated  to  beginners.  This  is  partly 
because  there  are  so  many  different  methods  or  modifications,  and 
partly  because  it  is  not  always  made  clear  that  all  these  different 
methods  are  but  different  ways  of  securing  one  or  both  of  the  two 
chemical  changes  desired:  (1)  oxidation  or  (2)  putrefaction;  each 
of  these  processes  causes  the  decomposition  of  organic  matter, 
changing  it  as  completely  as  possible  to  anorganic  substances.  The 
whole  process  might  be  summed  up  as  a  ''mineralizing  of  the  or- 
ganic wastes.^'  Some  systems  do  this  very  rapidly  and  very  com- 
pletely; in  some  systems  this  is  but  partly  accomplished  before  the 
sewage  is  discharged;  when  the  sewage  is  discharged  directly  {e.g., 
from  a  vessel  into  the  ocean)  no  such  changes  take  place  before 
discharge,  but  these  changes  take  place  in  the  ocean  itself. 

Disposal  without  Previous  Treatment. — As  Eosenau  says: 
"  The  basic  principle  that  underlies  all  methods  of  sewage  disposal 
is  to  get  rid  of  the  sewage  as  speedily  as  possible,  with  the  least 
nuisance  to  the  smallest  number  of  people,  with  the  least  damage 
to  health  or  property,  and  at  the  smallest  cost."  All  these  consid- 
erations vary  with  the  relative  denseness  of  the  population,  the 
chance  of  polluting  the  drinking  water,  the  possibility  of  using  the 
ocean  instead  of  inhabited  land  areas  for  sewage  discharge,  etc.  All 
this  means  that  often  we  must  hold  back  the  sewage  until  mineral- 
ization has  partly  or  even  completely  taken  place.  In  such  cases 
most  complicated  systems  of  "  purification  "  may  be  used. 

The  simplest  classification  of  these  water-carriage  systems  might 
be  on  the  basis  of  the  place  to  which  the  sewage  is  carried — the  land 


152  HOME  AND  COMMUNITY  HYGIENE 

or  the  water.  Discharge  into  the  ocean  is  a  very  simple  matter,  if 
the  discharge  pipe  is  below  low  tide  level  so  that  recurring  tides  do 
notjcarry  back  such  discharges.  It  is  equally  important  to  see  that 
all  community  interests  are  left  uninjured:  bathing  beaches  and 
oyster  beds  must  not  be  polluted;  sometimes  currents,  eddies,  etc., 
may  carry  such  material  quite  directly  to  houses  or  towns  some 
distance  away. 

Eiver-discharge  is  less  satisfactory,  especially  if  the  streams  are 
small,  or  if  towns  down  stream  are  too  close  to  allow  the  sewage  to 
be  diluted  with  a  margin  of  safety  before  they  take  out  their  drink- 
ing water,  use  it  for  bathing,  etc.  Sewage-polluted  rivers  have  an- 
other disadvantage.  The  large  amounts  of  oxygen  necessary  to  oxi- 
dize the  organic  sewage  may  take  oxygen  from  the  water  more 
rapidly  than  it  can  be  absorbed  from  the  air  above  the  water,  and 
fish  cannot  live  in  this  oxygen-poor  water.  Shad  fishers  in  the 
lower  Hudson  are  complaining  bitterly  over  the  difference  between 
the  catches  possible  now  and  twenty  years  ago.  The  heavy  pollution 
of  the  river  water  by  the  sewage  of  175  towns  and  municipalities, 
including  New  York,  is  a  large  factor  in  causing  this  relative 
scarcity. 

Lake  conditions  are  much  like  those  described  for  rivers  and  for 
the  ocean.  The  smaller  size  and  the  lack  of  current  in  many  lakes 
make  more  care  necessary  regarding  the  amount  of  sewage  and  the 
distance  of  the  discharge  pipe  from  the  shore  line.  If  large  amounts 
are  discharged,  it  may  be  necessary  to  extend  the  pipe  several  hun- 
dred feet  out  into  the  lake. 

Methods  of  Treatment  before  Disposal. — When  sewage  is 
emptied  directly  into  the  water,  the  bulk  of  the  water  with  which  it 
mixes  may  be  large  enough  to  prevent  the  sewage  from  being  a 
serious  menace.  In  time  many  of  its  original  bacteria  die  off  (see 
p.  104),  any  pathogenic  ones  it  originally  contained  disappearing 
quite  rapidly,  usually.  The  "  Chicago  canal  "  is  a  huge  sewer  which 
carries  Chicago  sewage  via  the  Illinois  Eiver  to  the  Mississippi ;  the 
natural  agents  have  by  that  time  so  affected  the  sewage  that  it  causes 
no  nuisance  to  towns  near  its  entrance  into  the  Mississippi  about 
three  hundred  and  fifty  miles  from  Chicago.  (See  p.  104.) 

In  most  cases,  it  is  better,  however,  to  treat  this  sewage  in  such  a 
way  that  it  will  not  be  dangerous  nor  even  objectionable  (e.g., 
odors)  before  it  is  discharged,  especially  if  it  is  discharged  on  land 


SEWAGE  DISPOSAL  153 

instead  of  into  water.  The  large  volume  to  be  handled  makes  some 
reduction  in  bulk  necessary,  for  the  sewage  to  be  disposed  of  averages 
daily  50  to  200  gallons  per  person.  This  reduction  in  bulk  is  secured 
by  screening,  sedimentation,  etc. 

Screening. — The  simplest  method  of  treatment  is  screening. 
Wire  screens  of  very  fine  mesh  are  often  used  to  hold  back  the 
coarser  materials,  and  the  finely  suspended  matter  and  all  the  liquid 
part  pass  through. 

Sedimentation. — Another  simple  way  is  to  let  the  sewage  stand 
in  some  kind  of  receiving  tank  while  the  solids  settle.  Since  sewage 
is  mostly  water  (less  than  1  per  cent,  solids),  this  means  that  with 
complete  sedimentation  relatively  little  bulk  would  thus  be  left  to 
care  for. 

Chemical  Precipitation. — Such  sedimentation  is  too  slow  a 
process,  however,  and  the  sedimentation  is  often  hastened  by  adding 
a  chemical  to  the  water.  Sewage  may  average  100  to  200  gallons 
per  day  per  person;  cheap  chemicals  must  therefore  be  used.  The 
commonest  ones  are  lime  and  iron  or  alum  salts.  These  help  pre- 
cipitate the  solid  particles  and  even  part  of  the  material  in  solution ; 
they  also  remove  one-half  to  two-thirds  of  the  organic  matter,  and 
lessen  public  nuisances  (odor,  etc.)  connected  with  the  liquid  dis- 
charged. Screened,  sedimented  or  chemically-precipitated  sewage  is 
much  easier  to  dispose  of,  for  the  liquids  can  be  allowed  to  run  into 
the  nearby  waters  without  so  much  danger  of  clogging  the  harbor 
or  filling  the  river  channel.  The  relatively  small  amount  of  solid 
material  or  sludge  can  be  more  easily  disposed  of:  buried,  spread 
out  upon  the  ground,  or,  as  is  done  in  London,  put  upon  scows, 
and  dumped  far  out  at  sea. 

These  methods  do  not  make  the  sewage  safe.  They  simply  make 
it  easier  to  dispose  of  the  bulk  found  in  most  cities.  Even  the  re- 
duced bulk  obtained  by  sedimentation,  precipitation,  etc.,  may  be 
difficult  to  manage,  it  may  amount  to  100  to  200  barrels  per  day  in 
towns  of  only  5000  people.  Sewage  disposal  is  a  bigger  problem 
than  merely  separating  out  this  sediment  or  sludge. 

Sewage  Farms  or  Broad  Irrigation. — It  is  well  known  that 
on  ordinary  soil  one  may  discharge  a  fair  amount  of  liquid  wastes 
without  any  noticeably  disagreeable  results,  e.g.,  dish-water.  If  the 
soil  is  open  or  sandy,  large  amounts  can  be  taken  care  of  without 
creating  any  objectionable  condition.    But  if  too  much  is  discharged 


154  HOME  AND  COMMUNITY  HYGIENE 

upon  it,  the  soil  becomes  water-soaked,  wet  and  sour.  In  inland 
cities  without  water  connection,  there  is  a  limit  to  the  amount  of 
slu(|ge  that  can  be  taken  care  of  on  the  limited  area  available  near 
large  cities  or  towns.  Because  of  the  organic  matter  in  sewage,  it 
was  thought  that  it  would  furnish  valuable  food  material  for  plants. 
Enthusiasts  forgot  to  take  into  consideration  the  low  percentage  of 
total  solids  in  sewage.  Irrigation  farms  were  started,  some  of  them 
on  a  gigantic  scale.  A  recent  report  indicates  those  in  Berlin  are 
now  being  discarded.  The  soil  in  all  cases  finally  becomes  clogged 
with  the  finer  particles  in  the  sewage  and  oversoaked  with  water. 
The  cultivation  of  water-loving  plants,  or  plants  with  much  leaf 
surface  (for  leaves  give  off  large  amounts  of  water),  has  not  helped 
materially  in  reducing  these  conditions.  When  sewage  or  sludge  is 
exposed  in  this  way,  there  is  always  some  danger  that  pathogenic 
organisms  may  still  be  alive  and  do  harm.  It  is  not  wise  to  grow 
vegetables  which  are  eaten  raw  {e.g.,  lettuce,  radishes)  on  such 
sewage-farm  land,  for  typhoid  organisms  have  been  found  on  plants 
grown  in  soil  manured  by  human  excreta. 

Subsurface  Drainage. — This  last  danger  is  avoided  when  the 
sewage  is  deposited  under  the  surface  of  the  ground.  The  sewage 
runs  along  a  branching  route  in  loosely  constructed  stone-walled 
ditches  or  drains  made  of  hollow  tiles  or  pipes  (Fig.  38).  These 
pipes  are  laid  with  their  joints  slightly  separated,  so  that  while 
most  of  the  sewage  passes  on  despite  the  loose  joints,  a  little  leaks 
through  at  each  joint.  This  is  absorbed  into  the  surrounding  soil, 
and  finally  decomposed  by  the  bacteria  present  there.  If  two  sys- 
tems of  such  drains  are  constructed  and  used  alternately,  the  soil 
has  a  chance  to  "  rest " — to  take  in  more  oxygen  from  the  air  and 
so  do  its  work  more  effectively.  Figure  38  shows  diverting  manholes 
to  accomplish  this  purpose.  For  subsurface  drainage  gardens  and 
cultivated  fields  may  be  used;  the  manurial  value  of  sewage  is  not 
entirely  lost  in  this  method. 

Filters. — If  sewage  deposited  in  or  on  the  soil  can  be  cared  for 
as  described — if  manured  and  other  surface-polluted  waters  can  pass 
into  the  soil  and  come  out  in  wells  or  springs  clear  and  quite  free 
from  bacteria — there  is  no  reason  why  this  filtering  action  cannot 
be  utilized  to  purify  sewage.  Huge  beds  of  sand  with  drains  or 
coarser  material  at  the  bottom  are  used  as  sewage  filtters  (see 
Fig.  31).    These  huge  filters  receive  crude  or  untreated  sewage  on 


SEWAGE  DISPOSAL 


155 


their  surface,  but  the  liquid  trickling  through  at  the  bottom  is 
clear,  odorless,  and  quite  free  from  bacteria.     People  sometimes 


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drink  it  fresh  from  such  filters  (without  any  other  treatment)  lust 
to  prove  how  effective  the  filters  are. 


156  HOME  AND  COMMUNITY  HYGIENE 

Such  filters  are  not  exactly  filters,  despite  their  name.  The 
action  seemed  like  that  at  first,  and  the  name  is  now  firmly  fixed. 
That  filtering  is  not  the  process  is  shown  by  the  fact  that  tight,  fine 
sand  filters  do  not  work  so  well  as  loose,  porous  ones.  If  the  process 
is  allowed  to  go  on  slowly,  the  effluent  which  passes  through  is  much 
clearer  than  when  the  passage  is  rapid.  This  shows  it  is  not  merely 
a  retention  or  filtering  process.  We  are  forced,  therefore,  to  con- 
sider the  filter  mainly  a  place  where  oxidizing  bacteria  come  into 
contact  with  the  organic  substances  in  the  sewage  and  decompose 
them.  Since  they  act  by  oxidation,  air  is  necessary.  The  coarse 
structure  at  the  bottom  allows  the  entrance  of  air.  Coarse  sand  has 
more  of  these  air  spaces  all  through  the  filter  than  fine  sand  has. 
On  all  the  surfaces  of  the  sand,  stones,  etc.,  these  oxidizing  bac- 
teria adhere,  making  a  general  covering  which  comes  into  close 
contact  with  the  sewage  passing  through. 

Intermittent  Filters. — Complete  aeration  of  these  filters  is  best 
secured  by  allowing  them  to  remain  unused  for  a  period.  In  prac- 
tice, therefore,  such  sewage  filters  are  always  intermittent  filters. 
Then,  as  in  the  resting  periods  advised  for  subsurface  drainage, 
fresh  air  passes  into  these  spaces,  thus  providing  more  oxygen  for 
the  oxidation  processes  necessary  to  take  care  of  the  next  lot  of 
sewage. 

Trickling  Filters. — ^There  are  other  ways  of  securing  sufficient 
oxygen  for  the  work  of  these  oxidizing  bacteria.  Instead  of  stop- 
ping the  flow  and  losing  hours  of  service  daily,  one  might  mix  air 
with  the  sewage  ^as  it  passes  into  the  filter.  We  therefore  find 
various  schemes  for  mixing  air  and  sewage.  The  most  effective  is  to 
empty  the  sewage  upon  the  bed  or  filter  by  a  series  of  pipes  from 
numerous  openings  in  which  the  sewage  spurts  up  in  sprays  or 
fountains,  falling  down  well  mixed  with  air  upon  the  coarse  stones 
on  the  upper  surface  of  the  filter.  This  filter  is  much  more  porous 
than  the  other  filters.     (See  frontispiece.) 

Activated  Sludge  Tanks. — A  recent  but  very  promising  way  of 
mixing  the  air  with  the  sewage  is  simply  to  collect  the  sewage  into 
tanks  and  pump  in  compressed  air  at  the  bottom  of  the  tanks. 
Large  amounts  of  air  can  be  forced  through  the  sewage  and  very 
rapid  oxidation  takes  place.  Small  particles  of  suspended  matter 
in  the  sewage  become  covered  with  a  slimy  bacterial  coating,  and 
these  are  kept  in  constant  movement  through  the  sewage  by  the 


SEWAGE  DISPOSAL 


157 


rising  bubbles  of  air.  When  the  liquid  is  allowed  to  run  off,  some  of 
the  sludge  is  kept  in  the  tank.  This  consists  mainly  of  the  bacteria- 
coated  particles,  which  "  activate  "  the  new  lot  of  sewage. 

Septic   or  Hydrolytic  Tanks. — In  all  of  the  water-carriage 
methods  described  above,  the  bacterial  action  depended  upon  the 


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Fig.  39. — Two  cesspools — one  made  of  loose  stone,  the  lower  one  of  hollow  brick  or 
tiles;  both  allow  "leaching"  of  the  contents  through  the  side  walls  and  through  the  earth 
bottom.  The  extension  on  the  right  of  the  lower  one  is  made  of  tile,  much  as  in  Fig.  38. 
Cesspools  that  overflow  have  been  made  satisfactory  by  such  tile  extensions. 


presence  of  oxygen.  As  stated  earlier,  there  is  another  important 
bacterial  process,  putrefaction,  which  may  aid  in  breaking  down  of 
sewage.  These  bacteria  do  not  do  so  well  in  well-aerated  places, 
such  as  trickling  filters.  Their  activity  is,  therefore,  greatest  in  the 
deeper  levels  of  the  sewage  tanks. 

If  sewage  is  allowed  to  stand  in  a  tank,  the  grease  tends  to  rise 


158 


HOME  AND  COMMUNITY  HYGIENE 


to  the  top.  This,  if  undisturbed  by  later  additions,  forms  a  film 
across  the  top.  Beneath  this  the  oxygen-using  bacteria  may  operate 
for  a  while,  but  soon  the  oxygen  is  used  up  and  the  bacterial  action 
is  of  the  other  type,  the  putrefying  type,  due  to  the  organisms 
which  do  not  need  free  oxygen  for  their  work.  In  time  these  bac- 
teria may  decompose  or  break  down  the  sewage  so  as  to  leave  very 
little  solids  or  sediment  in  the  tank.  To  such  tanks  is  applied  the 
name  "  septic  tanks."  Special  septic  tanks  have  been  constructed  to 
secure  more  complete  digestion  of  the  sewage ;  in  these,  sewage  is  re- 


Fig.  40. — Drawing  of  a  double  cesspool  which  has  not  been  cleaned  in  over  12  years, 
though  recei\'ing  all  house  waste  of  two  families  (or  a  total  of  seven  people).  What  is  the 
difference  in  the  bacterial  action  in  these  two  cesspools? 

tained  for  varying  periods  of  time — ^several  hours  to  one  or  even 
two  weeks. 

The  ordinary  cesspool  may  be  a  water-tight  structure  or  a  kind 
of  septic  tank.  Sometimes  cesspools  have  porous  or  loosely  con- 
structed walls,  which  act  like  the  subsurface  drainage  tiles  (see 
Fig.  39).  AYhere  houses  are  close  together,  or  where  wells  may  be 
contaminated,  the  tight  cesspool  is  more  desirable.  Cesspools  are 
preferably  constructed  in  pairs  (see  Fig.  40),  one  a  true  septic  tank 
and  the  other  a  leaching  (G)  pit.  In  such  paired  cesspools,  the  first 
or  septic  tank  is  usually  made  water-tight  (extra  inside  coatings  of 
pure  Portland  cement),  though  the  grease  collecting  on  the  sides 
tends  to  make  it  quite  waterproof,  anyhow.  If  the  inflowing  pipe 
ends  low  down  in  the  first  (right)  tank,  the  grease  film  on  the  top  is 


SEWAGE  DISPOSAL  159 

not  broken  as  the  sewage  flows  in,  and  better  putrefactive  ^  action 
may  be  secured.  The  carry-over  pipe  carries  over  the  liquid, 
leaving  the  solids  yet  undigested  in  the  bottom.  In  some  cases  the 
second  cesspool  empties  into  subsurface  drainage  pipes;  in 
many  cases  the  leaching  is  from  the  cesspool  itself,  as  shown  in  this 
figure.  Cesspools  should  always  have  an  overflow  pipe.  If  tight  or 
lined  cesspools  become  clogged,  sewage  may  back  up  into  the  house ; 
an  overflow  would  '^all  attention  to  the  difficulty  before  this  occurred. 

Contact  Beds. — ^The  double  cesspool  has,  therefore,  bacterial 
action  of  *^oth  types — mainly  putrefactive  in  the  first  part,  and 
mainly  oxidative  in  the  second.  The  "  contact  beds  "  have  both 
types  also.  They  are  simply  huge  open  shallow  basins  or  beds  of 
broken  stone,  brick,  etc.,  into  which  the  sewage  is  poured.  These 
beds  are  flooded  for  a  short  period  (two  hours)  and  then  emptied; 
empty  and  filled  periods  alternate.  When  filled,  putrefaction  takes 
place  in  the  liquid  mass ;  at  the  surface  and  near  the  spaces  in  the 
bottom  the  action  is  oxidative.  When  the  bed  is  empty,  oxygen 
enters  the  spaces  and  the  substances  clinging  to  the  stones  in  the 
bed  are  oxidized  by  the  bacterial  film  also  on  those  stones. 

Combined  Methods. — Omitting  the  mechanical  or  chemical 
clearing  of  sewage,  all  the  above  methods  of  specially  treating 
sewage  fall  under  the  headings  of  oxidizing  processes  or  putrefactive 
processes. 


Action 
Oxidation  Putrefaction 

Broad  irrigation 

Subsurface  drainage  Cesspool  (tight-walled) 

Intermittent  filter  Septic  tank 

Trickling  filter 
Activated  sludge 
Cesspool   (loose-walled) 


Combined  action 

Contact  bed   (mainly  oxidative) 
Double  cesspool 


^  As  "starters"  for  tight  cesspools  and  septic  tanks  one  or  two  shovel- 
fuls of  manure  are  sometimes  used. 


160  HOME  AND  COMMUNITY  HYGIENE 

Bacterial  Reduction. — The  various  methods  differ  in  the  rate 
at  wliich  sewage  bacteria  are  destroyed ;  e.g.,  fine  screens  reduce  the 
bafcteria  only  10  to  20  per  cent.,  sedimentation  25  to  75  per  cent., 
chemical  precipitation  40  to  80  per  cent.,  contact  beds  80  to  90  per 
cent.,  activated  sludge  process  85  to  95  per  cent.,  and  trickling 
filters  90  to  95  per  cent. 

They  differ  also  in  the  rate  at  which  sewage  is  "  purified."  Sub- 
surface drainage  can  take  care  of  150  to  200  people  per  acre 
drained;  intermittent  sand  filters,  of  1500  to  2000  people  per  filter 
acre;  contact  beds,  of  5000  per  acre,  and  trickling  filters,  of  10,000 
or  more  per  acre.  A  house  or  a  community  may  use  one  device  only 
or  more  than  one.  The  selection  depends  upon  the  character  of  the 
soil,  the  number  of  people  to  be  served,  the  place  of  final  discharge, 
and  upon  whether  or  not  the  effluent  (G)  is  to  be  used. 

Disinfection. — In  some  cases  such  reclaimed  water  is  used  for 
factory  purposes.  Such  water  should  be  disinfected,  though  people 
sometimes  drink  it  with  no  evil  results.  Sewage  that  is  in  a  partly 
decomposed  state  during  or  after  the  process  above  described  may 
be  dangerous.  It  depends  upon  how  completely  the  changes  under- 
gone have  affected  any  pathogenic  bacteria  originally  in  it,  or  how 
completely  such  bacteria  have  been  removed  by  filters,  etc.  The 
proximity  of  exposed  sewage  to  residences  is,  of  course,  important 
in  deciding  whether  disinfection  is  necessary. 

Trade  Wastes. — Streams  and  lakes  are  sometimes  polluted  by 
trade  wastes,  which  are  objectionable  but  are  not  usually  directly 
dangerous  to  health.  Indirectly  they  may  be  very  important :  some 
wastes  give  objectionable  colors  or  tastes  to  water  {e.g.,  dye,  gaso- 
line, and  petroleum  wastes),  cutting  down  thereby  the  potable  (G) 
water  available  to  the  community ;  acid  wastes  may  dissolve  cement 
l^asins,  etc. ;  others,  such  as  paper-mill  wastes,  may  interfere  with 
the  later  filtration  of  community  water.  In  some  towns  a  factory 
may  discharge  more  waste  than  the  rest  of  the  town;  such  wastes 
are  sometimes  high  in  organic  material,  adding  materially  to  the 
whole  sewage-disposal  problem.  All  extensive  processes,  such  as 
slaughtering,  tanning,  discharging  such  objectionable  wastes  should 
include  private  disposal  systems  (chemical  treatment,  sedimenta- 
tion, and  filtration)  which  would  protect  the  community.^ 

*  Incidentally,  this  would  be  a  great  economic  gain  { e.g.,  compulsory 
treatment  of  such  wastes  nets  paper  mills  15  cents  a  gallon  for  the  sulphite 
waste). 


SEWAGE  DISPOSAL  161 

One  of  the  newer  methods  of  chemical  precipitation  (p.  153), 
uses  acids,  e.g.j  sulphuric  acid,  when  certain  trade  wastes  are 
present.  This  method,  like  all  others,  reduces  the  bacterial  count 
greatly ;  it  also  allows  the  recovery  of  grease  and  furnishes  a  grease- 
less  fertilizer. 

Cost  of  Sewage  Disposal. — Sewage  disposal  can  never  be  made 
a  source  of  income.  The  total  solids  are  very  low — ^less  than  1  per 
cent.  The  sludge  is  valued  at  but  one  to  four  cents  per  ton;  and 
cannot,  therefore,  be  a -source  of  income.  London  has  two  millions 
of  tons  of  sludge  yearly  to  give  away,  but  is  forced  to  go  to  the  ex- 
pense of  carrying  it  fifty  miles  out  to  sea,  because  no  one  wants  it 
even  at  that  low  price.  The  use  of  human  excreta  in  China,  Korea, 
etc.,  has  led  people  to  bemoan  our  prodigality.  As  indicated  earlier, 
untreated  human  excreta  should  not  be  used  for  vegetables ;  chemi- 
cal treatment  brings  the  expense  up  to  the  cost  of  ordinary  and  less 
objectionable  fertilizers ;  the  idea  is,  besides,  displeasing  to  Ameri- 
cans. The  results  obtained  on  sewage  farms  make  Victor  Hugo's 
lengthy  and  heated  arguments  for  utilization  of  the  sewage  of  Paris 
interesting  only  from  a  literary  point  of  view. 

PROBLEMS 

1.  How  does  your  community  dispose  of  its  sewage? 

2.  How  many  methods  of  sewage  disposal  are  in  use  in  a  two-  or  three- 
mile  radius  of  this  building?     Is  any  of  them  a  menace  to  health? 

3.  Has  any  building  in  your  community  a  privy  or  pail  closet,  or  a 
dry-earth  closet  which  is  not  properly  attended  to?  What  would  it  cost 
( money  or  time )  to  make  it  safe  for  the  neighbors  ? 

4.  What  are  the  possible  dangers  attending  the  use  of  cesspools? 

5.  What  are  the  methods  of  rendering  the  sludge,  sediment,  and  efflu- 
ents safe?    (See  references  in  Appendix.) 

6.  Unless  your  State  publishes  a  similar  pamphlet,  send  for  the  Ken- 
tucky Sanitary  Privy,  published  by  the  Kentucky  State  Board  of  Health. 
What  can  you  do  to  secure  equally  good  arrangements  for  the  rural  districts 
of  your  State? 


See  Reference  List  at  end  of  Appendix. 


CHAPTEE  VIII 
REFUSE  DISPOSAL 

The  disposal  of  waste  water  {e.g.,  disliwater)  and  human  ex- 
creta is  discussed  under  sewage  disposal.  The  other  principal 
house  wastes  are  sweepings  (lint,  mud,  soot,  grit  from  pavements), 
ashes,  garbage,  and  rubbish;  this  last  term  includes  such  materials 
as  old  glass  and  tin  articles,  paper  and  rags.  In  cities  or  towns  is 
added  the  disposal  of  sweepings  from  the  street  (earth,  grit,  horse 
manure)  and  from  common  yehicles,  e.g.,  street  cars. 

Eosenau  estimates  that  in  New  York  City  such  wastes  total 
about  a  ton  per  person  every  year:  ashes,  1200  pounds;  garbage, 
200;  rubbish,  100,  and  street  sweepings,  300  pounds.  In  smaller 
cities  this  is  much  less,  but  the  relative  cost  per  person  does  not 
decrease  so  rapidly. 

Prompt  Removal  Desirable. — Eefuse  disposal  is  demanded  by 
the  generally  accepted  standards  of  cleanliness  and  convenience. 
The  accumulation  of  foodstuff  materials  generally  known  as  garbage 
may  allow  the  development  of  flies,  though  garbage  is  very  rarely 
allowed  to  stand  long  enough  for  that,  as  it  takes  ten  days  from  the 
egg  stage  to  the  full-grown  fl.y.  Tin  cans  or  other  water-holding 
rubbish  often  lie  around  for  longer  periods ;  accumulations  of  rain- 
water make  possible  new  broods  of  mosquitoes  every  ten  days.  Gar- 
bage should,  therefore,  be  removed  daily  during  fly-time ;  tin  cans, 
etc.,  should  be  removed  at  least  weekly. 

Garbage  Cans. — The  principal  hygienic  danger  is  due  to  the 
fact  that  the  odors  of  decomposing  garbage  attract  flies  from  still 
more  undesirable  localities,  e.//.^  privies  containing  excreta  of  people 
having  dysentery  or  typhoid.  Garbage  cans  should  therefore  be 
odor-tight  as  well  as  fly-tight.  It  is  probably  unnecessary  to  add 
that  they  should  be  water-tight,  for  otherwise  leakage  from  the  can 
will  cause  the  accumulation  of  evil-smelling  substances  in  the  soil 
around  it.  Cans  and  any  soiled  area  around  them  should  be  well 
sunned;  if  odors  persist,  burning  with  oil  is  a  cheap  cure.  Einse 
the  oil  around  in  the  can,  leaving  a  little  in  the  bottom — ^but  a  half 
inch  or  less — and  start  the  flame  by  dropping  a  match  on  a  piece 
of  paper  or  other  kindling  material.  Soiled  ground  can  be  burned 
162 


REFUSE  DISPOSAL  163 

in  this  way.  Such  treatment  is  rarely  necessary,  and  should  be 
done  by  careful  persons  because  of  the  danger  from  fire.  The  lid 
should  be  left  off,  of  course.  Garbage-can  lids  should  fit  so  well 
that  they  can  not  be  knocked  off  by  cats  or  dogs.  Garbage  should 
never  be  left  uncovered  at  any  time,  not  even  when  on  the  street 
awaiting  collection.  Even  "nice"  people  expose  such  disgusting 
masses  daily  to  the  view  of  all  passers-by  if  stringent  health  rules 
do  not  prevent. 

Disposal  of  House  Garbage. — If  the  community  has  no  refuse 
disposal  system,  each  house  must  care  for  its  own  garbage.  In 
some  localities  it  may  be  simpler  to  bury  it,  remembering  that  the 
less  soil  one  uses  as  a  covering  the  more  rapidly  the  material  will 
disintegrate.  The  soil  must  be  deep  enough  to  prevent  the  attrac- 
tion of  flies ;  dogs  or  cats  often  dig  up  such  deposits,  if  covered  too 
lightly,  and  one  must  consider  all  of  these  factors  in  disposing  of 
garbage  by  burial. 

Wire  baskets,  fitting  back  of  and  above  the  fireplace  grate,  can 
be  used  for  drying  garbage  so  that  later  it  can  be  burned  readily 
in  the  grate.  Stovepipes  are  sometimes  made  with  an  enlargement 
in  which  a  wire  basket  of  refuse  can  be  quickly  dried.  If  the  mass 
of  garbage  is  large  or  too  tightly  packed,  it  may  interfere  with  the 
draft  somewhat,  as  well  as  delay  rapid  drying.  Chimneys  can,  with 
little  extra  trouble  at  the  time  of  construction,  be  made  with  an 
outside  opening  into  the  flue  in  which  such  material  can  be  dried. 
The  door  to  this  opening  must,  of  course,  be  kept  tightly  closed  to 
avoid  interfering  with  the  draft. 

Home  Disposal  of  Other  Refuse. — In  the  individual  home 
papers  can  be  burned,  unless  the  methods  of  heating  and  cooking 
in  use  do  not  include  either  stoves  or  furnaces.  In  those  cases, 
incinerators  (skeleton  baskets  or  wire  frames)  may  be  used,  the 
resulting  ash  being  utilized  on  the  flower  beds  or  lawn.  Often 
these  incinerators  can  be  used  for  the  partial  sun  and  air  drying 
of  such  garbage  as  bean  or  pea  shells  and  corn  husks;  they  may 
then  be  burned  readily,  especially  if  mixed  with  the  daily  accu- 
mulations of  paper,  etc.  Ashes  are  more  of  a  problem,  unless  they 
can  be  used  to  fill  in,  for  paths,  etc.  Bottles,  tin  cans,  and  old 
bedsprings  are  always  a  problem — even  in  the  country,  as  illus- 
trated by  the  frequency  with  which  one  runs  across  deposits  of  such 
materials  on  the  edges  of  towns  or  in  out-of-the-way  places. 


164  HOME  AND  COMMUNITY  HYGIENE 

Collection  of  Community  Refuse. — When,  because  of  the 
closely  populated  character  of  a  community,  these  problems  be- 
come too  difficult,  community  systems  of  collection  and  disposal 
become  necessary.  These  may  mean  only  the  removal  of  ashes  in 
winter,  or  of  garbage  in  summer.  The  metliod  of  collection,  too, 
varies;  all  kinds  of  house  refuse  may  be  dumped  into  a  common 
cart,  or  the  various  types  may  be  collected  separately;  (1)  ashes, 
(2)  garbage,  and  (3)  papers  and  similar  inflammable  materials; 
tin  cans,  bottles,  etc.,  are  usually  collected  with  the  rubbish.  The 
method  of  collection  depends  upon  the  method  of  disposal. 

Dumping  as  a  Method  of  Disposal. — Eefuse  dumped  out  at 
sea  may  be  washed  back  to  the  shore  and  become  a  decided  nuisance, 
especially  if  it  includes  garbage.  When  there  is  no  low  ground 
to  fill  in,  coast  towns  often  dispose  of  such  wastes  at  sea.  Inland 
communities  often  fill  in  old  quarries,  marsh  lands,  etc.,  with  mixed 
refuse.  These  pits  are  usually  great  nuisances,  giving  forth  vile 
odors  and  breeding  mosquitoes  and  flies.  Such  eyesores  have  also  a 
bad  effect  upon  the  community  spirit  and  hygienic  standards  of 
any  locality.  Occasionally  such  pits  are  flooded  with  oil  and  burned 
over,  but  this  burning  is  usually  most  incompletely  done,  and  prac- 
tically does  little  more  than  add  to  the  odors  already  unbearable  to 
the  unfortunates  residing  within  short  distances.  Within  the  last 
year  a  community  within  sight  of  ISTew  York  City  was  still  main- 
taining a  huge  pest-hole  of  this  kind  nearly  a  quarter  of  a  mile 
long  and  within  a  few  feet  of  a  main  road ! 

Other  Methods  of  Disposal. — Adequate  methods  of  refuse  dis- 
posal are  usually  much  more  complicated.  There  are  two  distinct 
methods:  incineration  and  reduction  (see  pp.  334  and  397). 

Incineration. — Mixed  refuse  is  adapted  to  the  incineration 
method;  the  tin,  glass,  etc.,  are  picked  or  sorted  out,  and  the 
rest  is  burned  in  huge  furnaces  or  incinerators,  the  paper  and  ashes 
forming  sufficient  fuel  to  dry  and  burn  the  garbage.  The  end  prod- 
ucts are  ashes  and  steam.  This  ash  is,  of  course,  burned  at  a  high 
temperature,  often  over  650°  to  1100°  C.  (1202°  to  2012°  F.), 
and  is  free  from  odors,  organic  or  decomposing  substance,  as  well 
as  bacteria.  The  steam  may  be  used  for  heating  or  outside  com- 
merciiil  purposes  as  well  as  operating  the  disposal  plant;  where 
power  is  expensive  this  method  may  actually  be  a  source  of  revenue 
to  the  community,  being  sold  as  steam  or  in  the  form  of  electricity. 


REFUSE  DISPOSAL  165 

In  Minneapolis  the  refuse  accumulation  of  each  day  must  be 
wrapped  in  paper.  This  insuxes  good  mixture  of  inflammable 
paper,  and  leaves  more  air  spaces  in  the  mass  to  be  burned.  Every 
square  foot  of  grate  surface  can  take  care  of  one-half  to  two-thirds 
of  a  ton  of  refuse  in  a  day;  if  properly  done,  there  is  very  little 
odor  or  smoke.  This  method  is  more  popular  in  Europe  than  in  the 
United  States,  It  has  certain  advantages  in  regard  to  collection: 
the  ashes  soak  up  the  water,  preventing  dripping,  and  they  do  not, 
therefore,  form  objectionable  dust  during  collection  and  carting. 

Reduction. — Eeduction  is  more  popular  in  the  United  States 
than  abroad.  The  separation  before  collection  yields  ashes  for 
filling,  and  paper,  which  may  be  used  in  paper  making.  The  gar- 
bage is  the  part  that  undergoes  reduction.  While  the  apparatus  per- 
forming the  work  of  reduction  is  far  from  simple,  the  theory  can 
be  very  simply  explained  by  reference  to  the  diagram  following 
(Fig.  41).  In  the  best  systems  the  garbage  is  not  handled  by  hand 
at  all  after  it  is  dumped  into  the  collecting  cart.  The  scows  which 
carry  it  to  the  reduction  plant  have  a  tank  at  one  end  into  which 
the  water  from  the  garbage  is  allowed  to  run  off  during  transit. 
Huge  canvas  sheets  are  hung  between  the  scow  and  the  reduction 
plant,  and  as  the  material  is  dumped  into  the  first  tank  or  con- 
tainer (1)  the  undesirable  substances,  such  as  the  larger  bones,  are 
picked  out  by  machinery.  This  first  tank  is  a  steam-lined  chamber 
where  the  material  is  heated  eight  to  ten  hours,  at  a  pressure  of 
sixty  to  one  hundred  and  forty  pounds.  During  the  heating  in  this 
tank  the  material  is  flooded  with  naphtha  or  other  similar  volatile 
substance  not  miscible  with  water  and  having  a  higher  boiling  point 
than  water.  Both  the  water  from  the  garbage  and  the  added 
naphtha  are  continuously  vaporized  and  drawn  off  into  a  tank  (C) 
where  they  are  condensed  to  liquid  form  again  and  the  naphtha 
and  water  are  separated  by  gravity.  The  water  is  discarded,  but 
the  naphtha  runs  back  into  (G)  to  be  used  again.  This  heated 
garbage  is  constantly  stirred  until  it  becomes  a  dry  mass^  when  it 
is  again  flooded  with  the  naphtha  and  the  grease  extracted.  The 
grease  extracted  may  represent  1  to  3  per  cent,  of  the  garbage. 
The  dry  mass  left  in  tank  (1)  after  the  grease  is  extracted  is 
dumped  upon  a  coarse  screen  (2), where  the  coarser  particles  (bones, 
rags,  etc.)  are  taken  out,  and  on  to  another  finer  screen  (3)  where 
the  finer  material  drops  through  into  the  hopper   (H),  but  the 


166 


HOME  AND  COMMUNITY  HYGIENE 


coarser  particles  pass  on  to  a  grinder  and  then  afterward  they  are 
screened  and  collected  into  the  same  hopper  (H) .  The  material  col- 
lected in  the  hopper  is  used  in  making  fertilizer.  The  bones  are 
ground  up  and  sold ;  the  rags  are  also  marketable. 

In  the  system  described  the  heating  is  done  in  a  closed  tank,  and 
at  no  time  do  odors  or  gases  escape  to  the  outside  air ;  the  products 
are  all  sterilized  before  they  are  discharged,  so  there  is  no  nuisance 
or  danger  connected  with  properly  constructed  and  managed  re- 
duction plants.  The  process  is  a  very  quick  one — the  whole  proc- 
ess as  described  being  complete  in  twelve  hours.  About  20  per 
cent,  of  the  garbage  is  marketable  tankage,  which  can  be  put  upon 
the  ground  directly,  or  used  as  a  filler  for  fertilizer. 


Fig.    41. — Diagram   of   a    garbage    reduction    plant.      Garbage    is    received   through   the 
funnel-like  opening  above  1.     See  text  for  other  details. 


Other  Uses  of  Separated  Refuse. — When  refuse  is  collected 
separately  the  garbage  is  sometimes  used  to  feed  pigs.  If  discon- 
tinued a  few  weeks  before  the  pigs  are  killed,  there  is  no  objection 
to  its  use  for  this  pur23ose.  The  garbage  should  be  fresh;  if  not 
collected  daily,  it  should  be  sterilized  by  steam.  This  cooked  gar- 
bage may  be  mixed  with  grain.  Garbage  is  sometimes  sold  to  private 
parties,  though  there  are  a  number  of  community  "j)iggeries,"  about 
300  in  the  whole  United  States,  which  together  are  credited  with  an 
annual  production  of  52,000,000  pounds  of  pork. 

The  tin  cans  in  the  refuse  are  sometimes  melted  to  reclaim 
the  tin. 

The  money  value  represented  in  garbage  may  be  guessed  at  when 
one  reads  that  a  private  corporation  paid  the  United  States  nearly 
$450,000  for  the  garbage  in  the  stationary  camps  established  in  the 
United  States  the  first  year  after  our  entrance  into  the  war.  Ee- 
eent  Federal  reports  claim  that  from  a  ton  of  garbage  may  be  ob- 


REFUSls  DISPOSAL  167 

tained  enough  glj^erin  for  fourteen  shells,  enough  fat  and  acid  for 
seventy-five  pounds  of  soap,  and  enough  fertilizer  for  eight  bushels 
of  wheat.  This  is  not  so  severe  an  arraignment  of  small  communi- 
ties as  large  ones,  because  the  paying  recovery  of  such  substances 
is  only  possible  in  specially  constructed  plants  and  by  trade 
processes  (see  pp.  335  and  397). 

PROBLEMS 

L  Name  the  ways  in' which,  improper  methods  of  refuse  disposal  affect 
health. 

2.  What  is  the  method  of  refuse  disposal  used  in  your   community? 

3.  Name  the  most  important  products  resulting  from  the  economic 
destruction  of  garbage;  illustrate  by  towns  in  your  own  State. 

4.  Formulate  a  set  of  rules  for  the  household  covering  the  disposal 
of  refuse. 

5.  The  first  garbage  reduction  plant  in  the  United  States  was  estab- 
lished but  twenty-seven  years  ago  in  New  York  City:  has  this  affected 
the  methods  used  in  your  State? 

6.  What  should  be  done  with  house  refuse  in  the  farm  home? 

See  Reference  List  at  end  of  Appendix. 


CHAPTEE  IX 

TRANSFER  OF  DISEASE 

Early  Theories. — Although  1675  is  the  earliest  date  one  can 
give  for  the  actual  observation  of  bacteria,  there  were  advanced  still 
earlier  at  least  two  theories  of  the  transfer  of  disease  which  pre- 
suppose the  existence  of  such  minute  organisms : 

Fracastorius,  in  1546,  described  these  causes  of  disease  as  being 
of  a  glutinous  nature,  capable  of  reproduction.  Kircher,  in  1659, 
described  minute  living  worms  in  milk,  vinegar,  cheese,  and  putrid 
substances,  saying  that  they  "  swarmed  with  an  innumerable  brood 
of  worms  which  are  imperceptible  to  the  naked  eye." 

In  1675  Leeuwenhoeck,  a  Dutch  lens  maker,  studied  the  living 
organisms  present  in  saliva,  diarrhoeal  excreta  and  putrid  sub- 
stances. Even  though  his  lenses  were  far  superior  to  all  previously 
made,  the  organisms  he  described  were  probably  mainly  protozoa; 
some  suggest  streptococci,  and  there  is  little  doubt  that  some  of 
the  larger  motile  bacteria  were  seen.  That  he  called  them  animal- 
cules (little  animals)  means  nothing,  for  in  his  time  motility  was 
thought  to  be  an  animal  characteristic;  they  knew  nothing  of  the 
many  tiny  free-swimming  plants  at  that  time. 

Modes  of  Transfer. — That  disease  may  be  caused  by  a  transfer 
of  pus  or  other  material  from  external  lesions  (G)  was  recognized 
long  before  these  dates,  however.  Even  before  the  Christian  era 
lepers  were  compelled  to  avoid  contact  with  other  people;  the  few 
who  were  cured  had  to  burn  their  old  clothing,  bathe,  and  substi- 
tute fresh  clothes  before  returning  to  their  former  homes. 

The  Chinese  also  transferred  smallpox  in  a  mild  form  from  the 
sick  to  the  well  by  wetting  wool  with  pus  from  the  eruptions,  and 
placing  it  in  the  nostrils  of  the  person  who  desired  to  contract  the 
disease  and  so  secure  immunity.  The  Turks  later  transferred 
smallpox  by  inserting  pus  from  an  afflicted  person  directly  into 
the  blood  of  a  well  individual,  making  a  small  scratch  or  prick  in 
the  skin  to  inoculate  the  pus. 

These  early  theories  also  included  surmises  regarding  the  agents 
of  transfer  of  such  infectious  material. 
168 


TRANSFER  OF  DISEASE  169 

Air,  as  a  transfer  agent,  was  mentioned  by  Fracastorius  as  early 
as  1546.  In  fact,  air  has  always  very  generally  been  accepted  as  a 
transfer  agent.  It  has  even  shared  with  "  Divine  Providence  "  the 
unenviable  reputation  of  a  causal  agent.  Even  in  the  last  century 
night  air  and  marsh  air  were  generally  dreaded  and  avoided.  The 
Eollo  books  of  the  last  generation  described  the  passengers  in  an 
Italian  coach  as  sleeping  with  all  the  windows  shut  to  avoid  the 
pestilential  effect  of  the  "  night  air  "  as  they  travelled  over  certain 
malarial  regions. 

The  role  of  insects  responsible  for  the  fear  of  "  night  air  "  in 
the  instance  just  described  was  suspected  long  before  it  could  be 
proven.  Before  the  Middle  Ages  Indian  writers  tried  to  relate  in- 
fection and  the  mosquito,  a  theory  it  took  several  centuries  to  prove 
(malaria,  1896  or  1898;  yellow  fever,  1901). 

Kircher,  in  1658,  definitely  mentions  flies  as  transfer  agents, 
saying  "there  is  no  doubt  that  flies  feed  on  the  internal  secretions 
of  the  diseased  and  dying;  then  flying  away,  they  deposit  their  excre- 
tions on  the  food  in  neighboring  dwellings,  and  persons  who  eat  it 
are  thus  affected." 

It  is  now  known  that  disease  organisms  may  remain  suspended 
in  air;  especially  when  associated  with  fine  particles  of  dust  or 
lint,  which  act  as  buoys.  As  will  be  shown  further  on  in  this 
chapter,  it  is  unusual  for  diseases  to  spread  any  considerable  dis- 
tance by  air  alone.  The  indications  are  rather  that  the  transfer  is 
usually  more  direct — ^by  contact.  And  the  modes  of  infection  are 
often  classified  under  three  headings:  (1)  direct  transfer ;  (2)  in- 
direct transfer;  or  (3)  transfer  through  an  intermediate  host. 

Types  of  Transfer. — Contact  may  be  direct — as  when  nasal 
excretions  of  a  measles  case  are  transferred  by  a  common  handker- 
chief to  a  second  individual.  When  the  contact  is  made  by  food 
(including  milk),  air,  water,  and  soil,  it  is  usual  to  speak  of  the 
transfer  or  contact  as  indirect.     One  grades  into  the  other. 

The  transfer — more  or  less  direct — by  means  of  saliva  are  very 
graphically  described  by  Chapin : 

"Not  only  is  the  saliva  made  use  of  for  a  great  variety  of  purposes, 
and  numberless  articles  are  for  one  reason  or  another  placed  in  the  mouth, 
but,  for  no  reason  whatever,  and  all  unconsciously,  the  fingers  are  with 
great  frequency  raised  to  the  lips  or  the  nose.  Who  can  doubt  that  if  the 
salivary  glands  secreted  indigo  the  fingers  would  continually  be  stained 
a  deep  blue,  and  who  can  doubt  that  if  the  nasal  and  oral  secretions  con- 


170  HOME  AND  COMMUNITY  HYGIENE 

tain  the  germs  of  disease  these  germs  will  be  almost  as  constantly 
found  upon  the  fingers?  All  successful  commerce  is  reciprocal,  and  in 
tliis  universal  trade  in  human  saliva  the  fingers  not  only  bring  foreign 
secretions  to  the  mouth  of  their  owner,  but  there,  exchanging  it  for  his 
own,  distribute  the  latter  to  everything  that  the  hand  touches.  Tliis 
happens  not  once,  but  scores  and  hundreds  of  times  during  the  day's  round 
of  the  individual.  The  cook  spreads  his  saliva  on  the  muffins  and  rolls, 
the  waitress  infects  the  glasses  and  spoons,  the  moistened  fingers  of  the 
pedlar  arrange  his  fruit,  the  thumb  of  the  millcman  is  in  his  measure, 
the  reader  moistens  the  pages  of  his  book,  the  conductor  his  transfer 
tickets,  the  "  lady  "  the  fingers  of  her  glove.  Everyone  is  busily  engaged 
in  this  distribution  of  saliva,  so  that  the  end  of  each  day  finds  this  secre- 
tion freely  distributed  on  the  doors,  window  sills,  furniture,  and  play- 
things in  the  home,  the  straps  of  trolley  cars,  the  rails  and  counters  and 
desks  of  shops  and  public  buildings,  and,  indeed,  upon  everything  that  the 
hands  of  man  touch.  What  avails  it  if  the  pathogens  do  die  quickly?  A 
fresh  supply  is  furnished  each  day.  Besides  the  moistening  of  the  fingers 
with  saliva  and  the  use  of  the  common  drinking  cup,  the  mouth  is  put  to 
nimiberless  improper  uses  which  may  result  in  the  spread  of  infection.  It 
is  used  to  hold  pins,  string,  pencils,  paper,  and  money.  The  lips  are  used  to 
moisten  the  pencil,  to  point  the  thread  for  the  needle,  to  wet  postage 
stamps  and  envelopes.  Children  '  swap  '  apples,  cake,  and  lollipops,  while 
men  exchange  their  pipes  and  Avomen  their  hatpins.  Sometimes  the  mother 
is  seen  '  cleansing '  the  face  of  her  child  with  her  saliva-moistened  handker- 
chief, and  perhaps  the  visitor  is  shortly  after  invited  to  kissi  the  little  one." 

Cliapin  also  describes  kissing  as  a 

"  recognized  mode  of  direct  contact  infection.  The  certainty  of  this  mode 
is  illustrated  by  a  well  authenticated  incident  recently  recorded.  At  a 
small  party  of  young  people,  where  kissing  games  were  not  barred,  there  hap- 
pened to  be  a  young  man  with  a  syphilitic  sore  on  his  lip.  As  a  result  of  the 
party  eight  of  the  young  people  contracted  syphilis.  In  a  boarding  school  a 
girl,  wliile  beginning  to  develop  the  sore  throat  of  scarlet  fever,  received  her 
friends  in  her  room.  The  only  one  who  contracted  the  disease  was  the  one 
who  kissed  her.  There  was  infection  of  the  air  of  that  room  and  the  dis- 
ease spread  to  no  one,  but  by  direct  contact.  Numerous  other  instances  at- 
test the  importance  of  this  mode  of  infection.  Of  course,  it  is  expected  that 
lovers  wiU  continue  to  brave  this  source  of  danger,  but  is  it  not  reasonjible  to 
ask  others  to  reform?  Gushing  women,  Avho  kiss  their  neighbors'  children, 
and  school-girls  who  use  this  salutation  as  freely  as  a  shake  of  the  hand, 
should  learn  that  this  meaningless  use  of  the  kiss  disregards  the  canons  of 
good  taste,  as  it  certainly  does  sanitary  precepts." 

Most  of  our  common  diseases  are  apparently  transferred  by 
direct  contact,  though  the  list  of  those  due  to  insects  and  other  in- 
termediate hosts  is  growing  rapidly  and  includes  some  of  our  most 
dreaded  diseases,  such  as  yellow  fever,  typhus  fever  and  plague. 
Flies  which  carry  typhoid  organisms  from  the  fseces  of  one  person 
to  the  food  of  another  person,  play  the  same  role  as  water,  and 
typhoid  so  transferred  might  be  described  as  due  to  indirect  con^ 


TRANSFER  OF  DISEASE  171 

tact  (Figs.  42  and  43).  In  many  other  cases,  the  organisms  grow 
and  multiply  in  the  bodies  of  insects,  multiplying  greatly  the 
chances  of  spreading  such  diseases.     This  is  transfer  through  an 


Fig.  42. — On  the  left  the  fly  is  shown  in  the  act  of  regurgitating  material;  this  causes 
the  fly  "spots"  familiar  to  all.  Note  on  the  right  the  hairy  rough  character  of  the  foot 
much  magnified,  which  explains  why  so  much  material  adheres  to  it.     See  Fig.  43. 


Fig.  43. — A  plate  of  agar  over  which  a  small  insect  walked.     Howard  speaks  of  "the  fiy 
which  does  not  wipe  its  feet."     Shows  that  where  he  wipes  them  is  also  important. 

intermediate  host.     This  is  sometimes   called  biological  transfer, 
and  direct  or  indirect  contact  transfer  is  called  mechanical  transfer. 
These  terms  are  not  given  to  emphasize  any  importance  now- 
attached  to  them,  but  to  explain  their  usage,  as  they  are  in  quite 


172  HOME  AND  COMMUNITY  HYGIENE 

common  use.  Two  other  terms  which  have  been  the  source  of 
great  confusion  and  much  useless  discussion  are  contagious  and  in- 
fectious. Any  disease  that  can  be  transferred  from  one  individual 
to  another  is  contagious.  All  such  diseases  are,  of  course,  due  to 
micro-organisms  or  infectious  organisms.  Since  contagious  dis- 
eases are  all  infectious,  and  most  infectious  diseases  are  con- 
tagious, the  terms  have  always  been  troublesome.  Much  simpler  is 
the  use  of  the  word  communicable  for  all  diseases  that  can  be  trans- 
ferred from  man  to  man,  including  in  it  those  transferred  by  in- 
direct as  well  as  direct  contact.  In  contrast  to  communicable  dis- 
eases (typhoid,  tuberculosis),  we  have  the  diseases  transferred  by 
an  intermediate  host  (malaria,  yellow  fever). 

To  fully  understand  the  transfer  of  communicable  diseases,  we 
must  know  at  least  three  things : 

(1)  How  the  causal  organisms  leave  the  body  of  ill  people; 

(2)  How  they  are  transferred  to  other  subjects; 

(3)  Their  preferred  channels  of  infection  or  entrance  into  other 
subjects. 

Consult  the  following  table  (pp.  173-4)  for  condensed  informa- 
tion on  these  topics  for  our  most  common  communicable  diseases. 
Does  this  table  justify  the  warning  regarding  the  four  F's — fomites 
(G),  flies,  fingers,  food? 

Channels  of  Infection. — In  how  many  of  the  diseases  listed 
does  the  route  of  transfer  indicate  the  great  danger  in  the  very 
common  habit  of  coughing  or  sneezing  directly  into  the  air?  The 
more  direct  the  route,  the  greater  the  chances  of  infection,  for 
direct  contact  transfers  organisms  usually  much  more  vigorous  than 
those  which  have  been  for  hours  exposed  to  somewhat  unfavorable 
conditions,  such  as  drying,  effects  of  sunlight.  The  "  channel  of 
infection''  (or  method  of  entering  the  body)  is  quite  definitely 
fixed  for  some  organisms,  for  example,  typhoid.  This  organism 
ordinarily  causes  disease  only  when  it  gets  into  the  alimentary 
canal,  and  though  it  may  be  found  in  the  blood  during  illness,  its 
normal  and  one  constant  .habitat  is  the  lining  of  the  small  intestine. 
Tuberculosis  illustrates  remarkably  well  our  inability  to  predict  al- 
ways the  mode  of  entrance  from  the  lesions  which  are  found  in 
affected  people.  Even  in  pulmonary  tuberculosis  there  is  every 
reason  to  think  that  the  preferred  entrance  is  not  by  the  lungs  but 
by  the  alimentary  tract  and  that  tubercle  bacilli  entering  with  food 


TRANSFER  OF  DISEASE 


173 


Communicable    Diseases — Not    Needing    an    Intermediate    Host   for 

Transfer 


Disease 


Organisms  leave 
the  body 


Known  methods  of 
transfer 


Preferred  channel 
of  entrance 


Smallpox  1 . 


Syphilis . 


GonorrhcEa . . 


Ophthalmia 
neonatorum 


Trachoma . 
Tetanus . . . 


Typhoid. 


Secretions   from 

mouth  and  nose; 

faeces  and  urine; 

(?)  lesions 
Lesions,    infected 

tissues 


As  in  syphilis . 


Usually  a  gonor- 
rhoea! infection 


Eye  lesions . 


Common  in  nor- 
mal excreta  of 
herbivorous  ani- 
mals,   including 


Urine  or  faeces. 


Personal  objects 
(handkerchiefs, 
spoons,  etc.),  bed- 
ding; flies 

Direct  contact  with 
diseased;  mouth  le- 
sions to  cups,  spoons, 
pipes,  dental  instru- 
ments; or  any  le- 
sions to  towels,  bed- 
ding, razors,  or  via 
hands  to  food 

As  in  syphilis;  more 
often  transferred  by 
toilet  seats,  bath 
tubs  than  syphihs, 
especially  to  children 

At  birth  during  pas- 
sage through  genital 
tract,  or  by  hands 
of  infected  nurse, 
physician 

Towels,  handker- 
chiefs, fingers 

Through  soil,  dust, 
etc.,  infected  with 
fecal  material;  occa- 
sionally transferred 
by  soiled  hands,  in- 
struments, catgut 

Mouth  to  dishes,  ther- 
mometers, tongue 
depressors  or  trans- 
ferred by  kissing; 
more  often  by  hands, 
bedding,  etc.,  soiled 
with  fecal  matter  to 
milk,  food;  carried 
from  faeces,  etc.,  by 
flies  to  food;  faeces 
may  pollute  water; 
vegetables  grown  in 
polluted  soil  (water 
cress,  or  lettuce) 
may  transfer  it 


Probably  through 
the  respiratory 
mucous  mem- 
branes 

Directly  into  blood 
or  tissues  through 
breaks  in  the  skin 
or  through  deU- 
cate  membranes, 
as  in  genital  or- 
gans 

As  in  syphilis. 
Eyes  often  di- 
rectly infected, 
especially  at 
birth 

Eye 


Eye 

Directly  into  blood 
or  tissues  through 
wounds 


Through  mouth  to 
intestine 


This  might  be  classed  with  diseases  from  lower  animals  (p.  179). 


174 


HOME  AND  COMMUNITY  HYGIENE 


Communicable    Diseases — Not    Needing    an   Intekmediate    Host    for 
Tb.a'ssf'ek.— (Continued) 


Disease 


Organisms  leave 
the  body 


Known  methods  of 
transfer 


Preferred  channel 
of  entrance 


Tuberculosis 
(Human) 


(Bovine)^. . . 
Diphtheria.  .  . 


Measles 

Scarlet  fever. . 


Whooping 

cough 
Mumps 


Pneumonia . 

Influenza . . . 
Common  colds 
Meningitis.  .  . 

Infantile 

paralj'sis 

Cholera 

Dysentery. .  .  . 
Hookworm .  . . 


Leprosy . 


Sputum  mainly; 
also  lesions; 
fseces    occasion- 

ally 


Diseased  udder  or 

faeces 
Discharges  mouth 

and  nose 


As  in  diphtheria, 

especially  nose 
Probabh'     as     in 

diphtheria 
Secretions  of  nose, 

respirator}'  tract 
Secretions  of 

mouth  (saUvarj- 

glands?)  and 

nose 
Mouth,  nose  and 

respirator^'  tract 
As  in  pneumonia. . 
As  in  diphtheria. . . 
As  in  diphtheria, 

especially  nose 
Probabh'     as     in 

meningitis 

Excreta 

Excreta 

Excreta 


Uncertain;  lesions, 
probably  also 
sputum  and  fseces 


Kissing,  droplet  in- 
fection (coughing, 
etc.)  to  food,  con- 
tact soiled  fingers  or 
personal  objects 

To  milk 


Direct  contact,  as 
kissing;  ^-ia  fingers 
or  any  object  in  con- 
tact vdtb.  mouth  or 
fingers,  including 
droplet  infection 

^Is  in  diphtheria 

As  in  diphtheria 

As  in  diphtheria 

Direct  contact,  much 
as  above 


As  in  diphtheria 

As  in  diphtheria.  ... 
As  in  diphtheria.  ... 
As  in  diphtheria .... 

Direct  contact,  much 
as  above  ?  Stable 
fly? 

Much  as  in  t  j-phoid , . 
Much  as  in  t}'phoid  . . 
Mainlj'  through  skin. 


Probably  by  direct 
contact ;  flies  and 
other  insects 


Through  mouth; 
usually  via  the 
intestines  to 
lymph  vessels 
and  then  to  tis- 
sues, even  lungs 

As  above 

Throat — usually 
localized  there 


Probably  mainly 
through  nose 

Mouth  and  nose 
probably 

Alouth  or  nose 

Probably  mouth 
(or  nose) 


Mouth  and  nose 

Mouth  and  nose 
^louth  and  nose 
Aiouth  and  nose 

iNIouth  and  nose 


As  in  t^'phoid 

As  in  typhoid 

About  10  per  cen*-. 
as  in  typhoid; 
mostly  through 
skin  (bare  feet, 
infected  toilet 
seats  ?_)  (Fig.  44) 

Uncertain 


2  Really  belongs  vrith  diseases  from  lower  animals  (p.  179). 


TRANSFER  OF  DISEASE  175 

or  drink  are  washed  down  into  the  stomach  and  make  their  way 
from  the  intestinal  area  to  the  lymjjiiatics  and  from  them  to  the 
tissues,  including  the  lungs.  (This  is  supported  by  experimental 
work  and  by  autopsies  where  the  oldest  lesions  are  found  in  the 
intestinal  region,  younger  ones  in  the  lymph  nodes,  and  still  younger 
ones  in  the  lungs  themselves.) 

These  preferred  methods  of  entry  are  illustrated  by  the  following 
experiment.    If  typhoid,  streptococci,  and  diphtheria  organisms  are 


Fig.  44. — -Hookworms  making  their  way  into  the  skin.     These  are  two  to  four  times  natural 


size. 


rubbed  on  a  cut  in  the  skin,  such  as  the  hand,  the  cut  with 
typhoid  produces  no  lesion  at  all,  the  diphtheria  but  a  slight  one, 
but  the  streptococci-infected  cut  usually  produces  a  severe  infection, 
sometimes  a  general  and  fatal  blood-poisoning.  If  the  same  bac- 
teria are  rubbed  on  the  throat,  the  typhoid  produces  no  effect,  the 
streptococcus  causes  a  sore  throat  or  blood-poisoning,  but  the 
diphtheria  causes  typical  diphtheria.  If  the  three  are  given  in 
food,  typhoid  only  is  harmful,  producing  typhoid  fever.  Tetanus, 
similarly,  causes  lockjaw  when  the  organisms  get  directly  into  the 
subcutaneous  tissue ;  a  horse's  intestines  commonly  contain  tetanus 


176  HOME  AND  COMMUNITY  HYGIENE 

organisms,  but  it  is  only  "when  some  of  those  organisms — ^probably 
from  the  animal  own  manure — get  directly  into  the  tissues,  as  in  a 
nail  puncture  of  the  hoof,  that  the  horse  develops  lockjaw. 

Hookworms  (Fig.  44)  may  take  a  most  curious  path  through  the 
human  body.  They  may  be  taken  in  "wnth  food  and  water  as  indicated 
in  the  preceding  table,  or  they  may  penetrate  the  &kin  (e.g.,  bare 
feet),  find  their  way  to  the  lymph- vessels,  then  to  the  heart  and 
lungs  where  they  are  coughed  up  into  the  throat;  there  they  are 
swallowed,  lodging  in  the  small  intestine. 

Human  Carriers. — -ISrot  only  the  ill,  but  often  the  well,  should 
cry  "unclean,'^  for  healthy  human  beings  may  act  as  carriers  of 
disease  organisms.  Such  carriers  have  usually  had  the  disease  in 
question,  and  retain  virulent  organisms  (G)  for  a  time  after  they 
have  recovered.  Diphtheria  carriers  are  quite  common.  It  has  been 
estimated  that  2  to  3  per  cent,  of  all  diphtheria  cases  become 
carriers,  and  1  to  5  per  cent,  of  all  typhoid  cases.  Meningitis 
carriers  are  so  common  that  Eosenau  states  that  it  would  require 
military  aid  to  quarantine  all  the  meningitis  carriers.  They  have 
been  one  of  the  big  problems  in  our  military  camps  in  the 
recent  war. 

The  history  of  some  of  these  carriers  has  been  most  surprising. 
One  epidemic  of  over  400  typhoid  cases  in  New  York  City  was  traced 
to  an  employee  in  a  dairy  who  had  had  typhoid  forty-nine  years  be- 
fore; another  in  Washington  (D.  C.)  to  a  man  who  had  had  typhoid 
forty-five  years  previously.  "  Typhoid  Mary  "  has  had  more  than 
her  share  of  attention,  owing  to  her  detention  for  three  years  in  an 
efEort  to  overcome  this  condition.  Before  her  detention  she  had  a 
record  of  at  least  twenty-two  cases  of  typhoid  in  seven  different 
households,  the  cases  developing  in  practically  every  instance  two  to 
four  weeks  after  her  arrival.  On  giving  her  parole  not  to  cook, 
she  was  released;  and  at  her  own  request  given  work  in  one  of  the 
city  institutions.  She  disappeared,  however,  and  a  few  years  after- 
ward was  located  as  cook  in  a  maternity  hospital  where  twenty-five 
typhoid  cases  had  already  developed.  It  was  then  learned  that  since 
her  release  she  had  also  infected  a  friend  and  several  people  in  a 
small  sanatorium. 

Houston  describes  several  interesting  carriers  in  England.  One 
was  the  wife  of  a  master  baker  with  whom  the  apprentices  boarded; 


TRANSFER  OF  DISEASE  177 

practically  every  apprentice  became  ill  (stomach  and  intestinal  dis- 
turbances) shortly  after  entering  into  apprenticeship.  This  was 
interpreted  by  her  as  due  to  "  too  good  diet/'  Finally  one  of  the 
new  apprentices  died  of  typhoid,  when  the  woman  herself  was  dis- 
covered to  be  a  carrier. 

Another  is  the  case  of  a  cook  and  dairymaid  in  a  reformatory 
where  she  caused  twenty-three  cases  of  typhoid  in  one  summer,  one 
being  the  gardener's  wife,  who  had  received  nothing  from  the  in- 
stitution except  milk;  a  second  was  an  outdoor  policeman  who  was 
given  a  daily  allowance  of  milk  for  his  tea.  After  the  twenty-third 
case,  she  was  excluded  from  kitchen  and  dairy  work  and  no  new 
cases  developed.  She  had  had  typhoid  five  years  before,  and  was 
afterward  found  to  be  a  carrier ;  past  history  indicated  that  she  was 
responsible  for  outbreaks  in  at  least  two  other  institutions. 

Intermediate  Hosts. — ^The  third  method  of  transfer — ^by  in- 
termediate hosts — includes  rabies,  foot-and-mouth  disease,  bovine 
tuberculosis  and  cowpox.  The  last  two  were  included  in  the  previ- 
ous table;  bovine  tuberculosis  could  be  treated  more  easily  with 
human  tuberculosis,  and  cowpox  and  smallpox  are  but  different 
phases  of  the  same  disease.  Eabies  and  foot-and-mouth  disease  are 
transmitted  to  man  only  by  the  lower  animals — ^so  they  are  placed 
in  the  same  table  on  page  179.  Here,  too,  might  be  placed,  if 
present  knowledge  sufficed,  a  new,  persistent  mold  disease  recently 
described  as  due  to  bites  of  mice  or  similar  infections.  Such  inter- 
mediate insect  hosts  may  affect  us  also  indirectly  through  our  food 
supply,  e.g.,  the  tick  which  causes  Texas  fever  in  cattle  (Fig.  45). 

Micro-organisms  which  are  transferred  by  intermediate  hosts 
are  commonly  located  in  the  blood,  salivary  glands,  stomach  or  in- 
testines of  these  insects.  Protozoa  differ  from  bacteria  in  that 
many  of  them  go  through  a  series  of  definite  changes  or  phases — a 
life  cycle.  In  the  mosquito  the  organism  causing  malaria  passes 
through  several  peculiar  stages  in  the  stomach,  lymph,  and  the  so- 
called  "salivary  glands"  connected  with  the  biting  apparatus, 
whence  they  finally  make  their  way  into  the  blood  of  human  beings, 
where  other  peculiar  stages  develop.  In  diseases  like  malaria  (Fig. 
46)  and  yellow  fever,  where  the  parasite  goes  through  part  of  its 
development  or  serial  changes  in  one  animal  (man)  and  part  in 
another  (mosquito)  both  animals  are  necessary  to  complete  the 
whole  cycle  of  changes,  and  the  disease  is  usually  not  transferred 
12 


178  HOME  AND  COMMUNITY  HYGIENE 

until  certain  stages  adapted  to  the  conditions  met  in  the  other  host 
have  been  reached.  To  reach  these  transfer  stages  takes  several 
day's,  usually.  For  example,  mosquitoes  cannot  transfer  malarial 
parasites  to  man  until  they  have  undergone  twelve  days  of  such 
cyclic  changes  in  the  mosquito.  Yellow  fever  mosquitoes  must  ob- 
tain that  parasite  from  a  yellow  fever  patient  during  the  first  three 
days  of  his  disease,  and  they  cannot  transfer  it  to  other  people  until 
about  twelve  days  have  passed ;  they  retain  organisms  in  that  trans- 
ferable stage  the  rest  of  their  lives,  however. 


Fig.  45.  Fig.  46. 


i 


J  ') 


■'■*■%:■ 


r-.^ 


Fig.  45. — The  somewhat  pear-shaped  bodies  in  the  red  blood  corpuscles  are  the  pro 
tozoa  which  cause  Texas  fever;  they  are  transferred  through  the  bite  of  the  tick.  Note  the 
abnormal  shape  of  the  blood-corpuscles. 

Fig.  46. — This  illustration  shows  normal  red  corpuscles  from  human  blood;  find 
corpuscles  containing  one  malaria  organism;  three  such  organisms.  Explain  why  malarial 
people  are  often  ansemic. 

Such  peculiarities  made  it  very  difficult  to  trace  disease  transfer 
at  first.  Now,  when  we  find  limited  transfer  and  non-transfer 
periods,  we  are  very  sure  that  the  causal  organisms  have  such  cycles 
in  their  development,  that  they  are  protozoa,  not  bacteria.  For 
example,  tho  organism  causing  yellow  fever  may  be  Leptospira,  but 
any  bacteriologist  on  the  data  just  described  would  risk  his  repu- 
tation on  its  being  a  protozoon. 

Almost  all  the  human  disease  organisms  having  other  animals 
as  alternate  hosts  are  protozoa.  Two  or  three  are  due  to  molds, 
one  or  two  to  true  bacteria  {e.g.,  plague  cauised  by  Bacillus  pesrtis). 
The  following  table  gives  a  li&t  of  common  diseases  spread  through 
such  alternate  hosts: 


TRANSFER  OF  DISEASE  179 

Common  Diseases  in  Man  Contracted  from  Other  Animals 


Disease  in  man 

Other  host  or  hosts 

Parasite  '  causing  disease 

Insect  hosts: 

Malaria 

Many  species  of  mosqui- 
toes (mainly  Anopheles) 

One  species  of  mosquito 
■  {Stegomyia  calopus) 

The  tsetse  fly  (Glossina) 

Bedbugs,  lice,  ticks,  bit- 
ing flies 

^  (!)  Fleas,  (Xenopsylla 
and  Ceratophyllus) ;  (2) 
rats,  ground  squirrels 
and  related  rodents 

The  body  louse  (Pedicu- 
lus),  less  often  the  head 
-louse 

Dog   (horse,  cow,  skunk 
and  other  animals  bit- 
ten by  dogs) 

Cow  and  sheep  mainly; 
transferred  to  man  usu- 
ally through  milk 

Cow,     horse,     sheep, 
mainly;  transferred  to 
man  through   infected 
hides,    furs,    bristle 
brushes,  etc. 
Pig  and  rat  (also  dog, 
cat,  fox,  etc.) 

Pig,  cow,  dog  all  harbor 
tapeworms,  transferable 
to  man  through  meat 
or  by  dog  hcking  hands 

Plasmodium  (Hcemamoeba) 
(Fig.  46) 

Leptospira  ictero  hwm,or- 
rhaglce 

Trypanosoma  (Fig.  3) 
Spirochoeta 

Bacillus  pestis 

Probably  Bacillus  typhi- 
exanthematici 

Doubtless  "Negri  bodies" 
demonstrated   in   nerv- 
ous system;  transferred 
to  man  by  dogs  biting, 
hcking  breaks  in  skin 
Not  yet  isolated 

Yellow  fever 

Sleeping  sickness 

Relapsing  fever 

Plague  * 

TjT)hus  fever  ^ 

Other  hosts: 
Rabies 

F  0  o  t-a  n  d-m  o  u  t  h 
disease 

Anthrax 

Trichinosis 

Trichinella  (a  round  worm 
commonly     called     tri- 
china) 
Three   species    of    Taenia 
(a  flat  worm) 

Tapeworm 

^  See  Figs.  3  and  4  for  drawings  of  typical  protozoa. 

*In  both  of  these  diseases,  plague  and  typhus,  the  main  host  is  the 
rat.  Fleas,  if  their  normal  food  animal,  the  rat,  is  lacking  or  limited  in 
number,  attack  man,  thus  bringing  him  into  a  rat-flea-man  chain.  Three 
hosts  may  be  found  in  other  diseases;  e.g.,  pigs  often  eat  rats  or  offal  from 
slaughter  houses  or  faeces;  since  man  eats  pork,  a  rat-pig-man  series  is 
established  for  tapeworm  and  trichinosis. 


180  HOME  AND  COMMUNITY  HYGIENE 

This  list  may  some  day  have  added  to  it  other  common  insect 
hosts :  the  bedbug  for  tuberculosis  and  leprosy,  and  the  stable  fly 
fo?  infantile  paralysis.  At  present,  evidence  does  not  warrant  in- 
cluding them  in  this  list. 

Direct  Control  of  Intermediate  Hosts. — The  control  of  these 
diseases  transmitted  to  man  by  insects  or  other  small  animals  is 
accomplished  by  breaking  the  chain. 

This  may  be  broken  in  several  ways:  (1)  by  getting  rid  of  the 
intermediate  host:  without  rats,  no  plague;  without  mosquitoes, 
no  malaria.  There  is  no  reason  why  more  energy  and  money  should 
not  be  expended  in  getting  rid  of  rats,  animals  both  filthy  and  de- 
structive in  habits.  The  economic  loss  to  farmers  and  to  big  busi- 
ness houses  (textiles,  grains,  and  other  foods)  is  estimated  at  thirty- 
five  to  fifty  million  dollars  yearly.^  Though  it  seems  a  hopeless 
task,  any  reduction  in  their  numbers  is  to  be  welcomed.  Pest- 
ridden  cities  have  conducted  campaigns  (poisons,  traps,  and  fumi- 
gation) with  good  results. 

Indirect  Control  through  Environment. —  (2)  Other  inter- 
mediate hosts,  such  as  the  mosquito,  are  still  more  difficult  to  ex- 
terminate. Although  the  Panama  Canal  is  a  wonderful  monument 
to  sanitary  science  in  its  control  of  yellow  fever,  it  must  be  re- 
membered that  that  was  a  relatively  small  area  when  compared  with 
our  whole  country,  and  that  such  scientific  and  complete  control  of 
the  whole  United  States  is  not  possible,  without  some  degree  of 
federal  health  control. 

The  extension  or  spread  of  malaria,  yellow  fever,  and  similar 
insect-borne  diseases  to  entirely  new  areas  is  usually  due  to  an 
infected  person  who  migrates  to  that  region  and  infects  the  mosqui- 
toes, which  spread  the  disease  by  biting  other  people.  Insects  them- 
selves do  not  travel  far,  unless  carried  (trains,  wagons,  etc.). 

Control  through  Care  of  Excreta. — (3)  A  third  way  of 
limiting  the  transfer  of  diseases  due  to  intermediate  hosts  is  by 
greater  care  of  our  body  wastes.  Unclean  habits  in  cattle  yards  or 
in  the  fields  where  pigs  and  cows  are  kept,  make  it  possible  for 
these  animals  to  become  infected  with  the  tapeworm  eggs.     Dogs 

"  See  the  National  Geographical  Magazine  for  July,  1917,  for  a  well- 
illustrated  description  of  the  rat  peril. 


TRANSFER  OF  DISEASE  181 

that  run  at  large  become  infected  with  eggs  from  sheep,  pigs  and 
cows;  such  dogs  may  be  dangerous  pets,  for  the  eggs  from  fecal 
material  which  they  transfer  to  man  when  licking  his  hands  may 
promptly  find  their  way  into  the  human  intestine. 

Control  through  Food. —  (1)  In  a  few  cases,  man  may  break 
the  chain  by  proper  treatment  of  his  food;  underdone  beef  and 
pork  may  transfer  their  respective  tapeworms,  and  thorough  cooking 
is  desirable  especially  for  pork  (see  p.  52).  The  large  amount  of 
cold  storage  meat  in  oiir  present  meat  supply  is  an  added  safeguard, 
especially  for  beef.  Pasteurization  of  milk  destroys  bovine  tubercu- 
losis (as  well  as  human  organisms  that  may  find  their  way  into  it). 

In  diseases  transferred  from  man  to  man,  we  endeavor  to  pre- 
vent their  spread  by  disinfection  and  by  framing  rules  of  conduct 
with  regard  to  our  foods  and  personal  habits.  While  these. are 
implied  more  than  once — in  this  and  other  chapters — it  may  be  of 
service  to  repeat  them  here: 

(1)  Avoid  the  use  of  articles  or  appliances  used  in  common:  tov/els, 
soaps,  drinking  cups,  pencils,  etc. 

(2)  Wash  the  hands  thoroughly  after  handling  articles  used  in  com- 
mon and  before  eating. 

(3)  Eat  and  drink  less  from  unknown  sources.* 

(4)  Avoid  crowded  places,  especially  in  epidemics  of  colds,  pneumonia 
and  influenza.'' 

(5)  Support  and  insist  upon  the  reporting  of  communicable  diseases, 
that  quarantine  and  disinfection  may  help  prevent  further  transfer  of 
disease.  In  some  cases  it  may  be  your  duty  to  be  vaccinated  against 
virulent  diseases,  such  as  smallpox.     (See  Chapter  X.) 

(6)  Having  framed  such  a  set  of  rules  for  general  conduct,  adhere 
to  them;  make  them  a  matter  of  habit  and  forget  the  reasons.  It  is 
almost  as  foolish  to  think  constantly  of  the  reasons  why  these  rules  are 
wise  and  necessary,  as  it  is  to  refuse  to  consider  or  follow  them.  The  former 
is  depressing  and  probably  injurious  to  you;  the  latter,  dangerous  not  only 
for  you  but  for  your  whole  community. 

'  Most  people  eat  constantly  while  out  on  a  picnic  or  jaunt,  and  almost 
without  question  as  to  the  effect  upon  the  digestive  apparatus  or  as  to 
the  bacterial  cleanliness  of  the  food  consumed. 

*  If  transit  companies  cannot  be  forced  to  supply  sufficient  transpor- 
tation facilities,  slightly  varying  working  hours  should  be  arranged  (be- 
ginning at  8.15  instead  of  8,  closing  at  5.30  instead  of  5)  for  several  of 
the  biggest  corporations,  schools,  etc.,  thus  lessening  the  danger  through 
crowded  conveyances. 


182  HOME  AND  COMMUNITY  HYGIENE 

PROBLEMS 

1.  List  the  habits  or  actions  noted  in  one  day  that  would  help  spread 
a  throat  or  nose  infection,  such  as  a  common  cold. 

2.  What  mechanical  devices  can  you  suggest  for  decreasing  such 
opportunities  for  transfer  {e.g.,  doors  opening  by  foot  devices  instead  of 
handles)  ? 

3.  What  important  facts  concerning  disease  transfer  are  not  generally 
known  in  your  community?  Suggest  ways  of  presenting  them  to  insure 
full  recognition  of  their  importance. 

4.  Write  a  popular  article  designed  to  interest  a  special  group  of 
people  in  protection  against  one  disease;  e.g.,  school  children  against  com- 
mon colds,  or  against  transfer  of  dysentery  by  cooks  and  waiters. 

5..  New  York  City  has  a  law  demanding  that  waiters  and  food  handlers 
(hotels,  restaurants,  push  carts)  be  examined  yearly  to  show  that  they 
are  free  from  tuberculosis,  typhoid  and  syphilis.  Has  your  city  such  a  law? 
How  could  such  a  law  be  secured  for  your  city? 

6.  Would  the  following  rhyme  make  more  impression  than  a  prose 
statement?    Use  this  same  treatment  for  a  similar  situation. 

"Mary  had  a  little  cold 

That  started  in  her  head. 
And  everywhere  that  Mary  went 
That  cold  was  sure  to  spread. 

"It  followed  her  to  school  one  day. 
There  wasn't  any  rule; 
It  made  the  children  cough  and  sneeze 
To  have  that  cold  in  school. 

"The  teacher  tried  to  drive  it  out. 
She  tried  hard,  but,  ker-choo! 
It  didn't  do  a  bit  of  good, 
For  teacher  caught  it,  too." 

7.  Many  people  take  off  their  rings  and  hold  them  in  the  mouth  while 
■washing  their  soiled  hands.    Criticise. 

8.  Waving  the  handkerchief  is  a  form  of  salute  often  used  in  public 
demonstrations  or  gatherings.     Explain  why  it  may  be  dangerous. 

9.  Show  why  people  who  "bite  and  spread"  as  they  eat  a  piece  of 
bread  should  be  careful  to  avoid  putting  their  knives  back  into  the  common 
butter  dish. 

10.  It  has  been  well  said  that  most  of  the  observances  called  "good 
manners"  have  hygienic  significance,  e.g.,  covering  the  mouth  when  cough- 
ing.    How  many  other  instances  can  you  find? 

11.  How  might  the  handkerchief  be  used  more  effectively  in  reducing 
disease  transfer?  Show  that  visible  dirt  is  not  the  sole  criterion  for  dis- 
carding a  handkerchief. 

See  Reference  List  at  end  of  Appendix. 


CHAPTER  X 
DISINFECTION  AND  QUARANTINE 

Centuries  ago  we  find  observation  of  quarantine  periods.  In 
India,  houses  of  the  dead  might  not  be  entered  for  varying  periods 
after  certain  diseases,  commonly  three  to  fourteen  days.  A  forty- 
day  seclusion  was  demanded  for  plague.  The  word  quarantine  is 
an  Italian  word  {quarante,  forty)  and  dates  back  to  the  middle 
ages  when  Venice  and  other  Italian  cities  detained  vessels  with 
plague  aboard  forty  days. 

Federal  Quarantine. — Ships  entering  our  country  from  foreign 
ports  are  required  to  bring  a  bill  of  health  from  our  own  consul 
at  the  port  of  departure.  This  contains  such  necessary  details  as 
the  number  in  the  crew,  number  of  passengers,  source  of  the  ballast 
(usually  water;  often  sand  containing  street  sweepings,  etc.),  and 
deaths  at  the  port  of  departure  from  the  six  quarantine  diseases 
for  two  weeks  preceding  the  date  of  sailing.  Besides  this,  the  ship 
must  present  at  port  of  entry  a  list  of  all  illnesses  since  sailing, 
present  all  passengers  and  crew  for  inspection,  allow  the  ship  and 
cargo  to  be  inspected;  disinfect  such  articles  as  are  open  to  sus- 
picion {e.g.,  hides,  hair,  fur,  which  often  bring  in  anthrax). 

The  federal  government  has  interstate  quarantine  power  for 
some  twenty  diseases  (p.  375)  ;  typhus,  yellow  fever,  plague,  small- 
pox, cholera,  leprosy  are  the  ones  for  which  incoming  vessels  are 
quarantined  (maritime  quarantine).  A  few  States  have  interstate 
agreements  regarding  typhoid  fever,  tuberculosis,  measles,  foot- 
and-mouth  disease,  but  more  definite  control  is  needed,  and,  as 
recommended  elsewhere,  federal  control  would  do  much  to  unify 
and  support  satisfactory  State  control. 

Quarantined  boats  and  buildings  are  usually  disinfected  after 
the  patients  have  recovered,  or  have  been  removed  to  hospitals,  etc., 
and  then  quarantined  for  the  known  incubation  period  of  the  dis- 
ease, five  to  fourteen  days.  Instead  of  simply  waiting  for  the  or- 
ganism to  die  as  in  the  old  idea  of  quarantine,  disinfection  is 
resorted  to,  to  kill  off  most  or  all  of  the  organisms  on  the  furniture, 

183 


184  HOME  AND  COMMUNITY  HYGIENE 

bedding,  etc.  This  decreases  the  detention  period  to  the  time  neces- 
sary for  new  cases  to  develop. 

Isolation. — Individual  quarantine  or  isolation  is  a  slightly  dif- 
ferent matter.  In  certain  diseases  the  patient  may  become  a  car- 
rier, thus  prolonging  the  necessary  period  of  isolation.  In  all  such 
conditions  isolation  must  continue  until  the  patient  is  no  longer 
discharging  virulent  (G)  organisms.  Isolation  of  stricken  indi- 
viduals is  not  a  complete  safeguard  in  all  eases.  In  measles, 
for  example,  for  about  three  days  preceding  the  usual  recognition 
of  the  disease  the  nasal  discharges  are  very  infectious.  Isolation 
should  be  adopted  as  soon  as  a  communicable  disease  is  recognized, 
to  prevent  further  infection  of  the  well.  To  safeguard  against  this, 
it  is  becoming  customary  to  demand  microscopic  evidence  in  the 
diseases  in  which  present  knowledge  renders  it  possible ;  for  example, 
in  diphtheria  city  departments  of  health  often  demand  that  the 
microscopic  examination  of  sputum  be  negative  (diphtheria  bacilli 
absent)  in  three  consecutive  examinations  before  the  patient  is  re- 
leased from  quarantine. 

House  Quarantine. — It  is  now  recognized  that  the  complete 
quarantine  formerly  thought  necessary  may  be  modified  in  certain 
diseases  without  harm  to  the  rest  of  the  community.  Eosenau  says 
quarantine  must  be  a  sieve  or  filter,  not  a  dam ;  that  it  must  be  en- 
forced with  the  least  hindrance  to  trade  and  travel.  It  must  also 
consider  the  health  of  the  infected  individual  and  partial  freedom 
should  be  allowed  whenever  possible.  In  some  cases,  such  as  whoop- 
ing cough,  it  is  possible  to  allow  considerable  freedom  (motoring, 
walking  on  street  with  responsible  attendants)  if  the  patients  are 
careful  to  avoid  close  contact  with  others,  avoiding  street-cars, 
shops,  etc.,  and  all  susceptible  individuals,  such  as  other  children. 

In  yellow  fever  it  is  sufficient  to  keep  the  patient  in  a  com- 
pletely screened  room,  as  the  organisms  causing  yellow  fever  can 
only  leave  his  body  or  enter  the  body  of  another  through  mosquito 
bites.  (It  is,  of  course,  necessary  to  make  sure  that  no  mosquitoes 
are  also  screened  in — and  that  occupants  of  the  house  do  not  carry 
mosquitoes  in  with  them.) 

Unfortunately,  public  sentiment  does  not  yet  wholly  support 
quarantine,  and  the  restrictions  are  too  often  looked  upon  as  some- 
thing to  avoid.    In  some  communities  a  guard  may  be  necessary  to 


DISINFECTION  AND  QUARANTINE 


185 


secure  protection  for  the  rest  of  the  community.  The  greater  de- 
pendence upon  hospitals,  the  more  general  tendency  to  call  for  the 
services  of  a  private  trained  nurse,  or  the  aid  of  visiting  nurses, 
and  the  gradual  education  of  the  people  through  the  schools  (school 
nurse,  enforced  absence  for  evident  infection)  are  all  having  effect. 


H-  visit'ed  by  (>a(iy««it^ 
cold'  later  want  to  hre 

with  C*  family  in  town 

of  B-. 


C-  Horne 
H'here  developed  measles 
Doctor  fordoU  Id  report  caie 
J  other  Cases  aeveiopeanere 


K-H.gfiScUI 

attended  by 


Town  of   K~ 
Total  caiei 82+ 


B-  District 
School  attended 
by  C- children 


Town  of 
7ot«lca5(s-l33+ 


Toyrv  of  N- 
Total  cases-20 


Fig.  47. — A  case  of  measles  in  which  the  doctor  "forgot"  to  file  the  card  reporting  the 
disease.  This  resulted  in  over  270  cases  of  measles  in  three  adjoining  towns  in  New  York 
State  (including  several  unreported  cases).     (Based  on  data  in  Health  News,  N.  Y.) 

Quarantine  will  always  miss  a  few  cases — non -typical  ones,  or  cases 
so  slight  that  the  disease  is  not  properly  diagnosed ;  healthy  carriers 
may  transfer  organisms  wholly  unsuspected  for  years,  especially  if 
there  are  a  number  of  immune  people  in  his  contact  groups.  In 
such  conditions,  new  cases  may  continue  to  develop  even  with 
strict  isolation  of  known  cases.  This,  of  course,  is  not  an  argument 
against  quarantine,  as  the  number  of  cases  would  doubtless  be  still 


186 


HOME  AND  COMMUNITY  HYGIENE 


greater  if  no  quarantine  were  enforced.     Every  effort  should  be 
m^de  to  make  this  clear  to  the  members  of  the  community. 

There  is  still,  however,  great  need  for  public  education  con- 
cerning the  necessity  for  quarantine  or  isolation  of  the  sick,  because 
most  sick  persons  are  cared  for  at  home  by  untrained  people ;  but  a 
very  small  per  cent,  of  ordinary  communicable  illnesses  are  cared 


OM  TRAItt-APniL  I 


CMILIREN  IH    P.    EXP05EI 


PROMPT  ACTIOH 
OF  MtAUM   OFFICER 


|E.C.|  |A.G.|  |D.G. 

Contact  At  Same  BoAROiMo  House 

innunt  •QUARwrrmt  unmecessary 


PAREKTa  MOTlflEO 
3U»FI&T»   QOAIWtTmCO  M 


RESULTS 


/     / 


OEVElOPEO   MEj<3Lta    APRIL  e» 


.MO     FURTHER     CASES      DEVELOPED   y 


Fig.  48. — When  Dorothy  developed  measles  her  mother  recalled  a  train  companion 
of  a  few  days  before  from  whom  she  had  evidently  contracted  measles.  The  health  officer 
was  notified  and  he  at  once  quarantined  all  marked  X,  thus  checking  the  spread  of  the  disease. 

for  in  hospitals  or  by  fully  trained  nurses.  The  proofs  of  the  value 
of  quarantine  are  all  negative  ones,  and  it  is  hard  to  make  people 
realize  that  "  every  case  isolated  is  a  focus  neutralized."  That  is 
illustrated  by  the  accompanying  diagrams  showing  the  effects  of 
isolation  and  non-isolation  of  cases  of  measles  (Figs.  47  and  48). 

The  main  problems  in  quarantine  are  probably  (1)  those  con- 
cerning children  (Fig.  49),  and  the  overcoming  of  the  idea  that  "it's 
better  to  have  it  and  be  done  with  it,"  and  (2)  our  own  responsi- 
bility for  foregoing  pleasure  or  business  when  affected  with  colds, 
sore  throat,  etc.  As  long  as  laws  do  not  demand  such  self -isolation, 
few  are  public  spirited  enough  to  demand  it  of  themselves. 

School  Regulations. — The  fold-in  chart  opposite  page  186 
(Fig.  49),  is  taken  from  Health  News  and  gives  detailed  regulations 
for  children's  diseases. 


PARTMENT  0 

^SES  AM^ 

)  EXCLUSK' 


Education 


NEW  YORK  STATE  DEPARTMENT  OF  HEALTH 

COMMUNICABLE  DISEASES  AMONG  CHILDREN 

RULES  FOR  ISOLATION  AND  EXCLUSION  FROM  SCHOOL 


^ 


CHICKEN  POX 


POLIOMYELITIS 


SCARLET  FEVER 


WHOOPING 


Rarely  begins  with  fever  Rash  appears 
second  day  as  small  pimples,  which  in  about 
a  day  become  filled  with  clear  fluid.  This 
fluid  becomes  yellow  colored,  a  crust  forms 
and  the  scab  falls  of!  in  about  14  days. 
Successive  crops  of  papules  appear  until 
tenth  day 


be  rapid  or  gradual.    The  back 
r  palate  i         "' 
mounced 
•  may  be  hardly  ; 


Begins  like  cold  in  the  head,  with  running 
■  "  '  '  tery  eyes  and 
Lppear  about 
behind  the 
ears,  on  forehead  and  face.  The  rash  vai 
with  heat:  may  ahnost  disappear  if  the  aii 
cold,  and  come  out  again  with  Warmth. 


Illness  usually  slight.  Onset  sudden.  Lymph 
nodes  in  back  of  neck  enlarged.  Rash  often 
first  thing  noticed 


t  fever,  variable. 


Onset  may  be  sudden,  beginning  with  sickness 
and  fever,  and  pain  about  the  angle  of  the 
jaw.  The  parotid  glands  become  swollen 
and  tender      Opening  the  mouth  is  a 


Onset  sudden,  fever,  excitable,  pain  on  bend- 
ing neck  forward,  pain  on  being  handled, 
headache,  vomiting.  Sometimes  sudden 
development  of  weakness  ,of  one  or 


the  skin  peels 


1  days,  when  it  fades  t 


of  constitutional  symptoms  red  shotlike 
pimples,  felt  below  the  skin,  and  seen  first 
about  the  face  and  wrists  most  on  exposed 
surfaces,  develop.  They  form  little  blisters 
and  after  two  days  more  become  fille  ' 
yellowish  matter.  Scabs  form  whicl 
to  fall  off  about  the  fourteenth  day. 


s  ends  with  vomiting. 


throat  or  bowels  of 


Discharges  from  nost 
and  mouth,  sup 
purating  glands  01 
ears  of  a  patient. 
Milk    may   convey 


cles  of  skin  or  scabs 


•  Immunes  are  those  who  have  had  the  diseases  o 


Duration  of  Exclusion  e 


Until  all  scabs  are 
shed  and  disinfec- 
tion of  person;  at 


covered     and 

throat  and  nose 
■which  contain  nc 
diphtheria  bacilli 
cultures  not  to  b€ 
taken  until  9  days 
from  date  of  onset. 
Disinfection  of  pcr- 


disinfection  of  pe 
son;     at     least 
days  from  onset 


Until  recovery  anc 
disinfection  of  per- 
son; at  least  8  dayf 


Two  weeks  after  c 


disinfection  of  t 


Recovery  and  disin- 
fection of  person ;  a1 
least  14  days 


Eight  weeks  or 

r  week  after  last 
;  charactetistic  cough 
,  and  disinfection  i  ' 


Children  who  leave 
household  as  soon 
as  disease  is  dis- 
covered 


til  2ist  day  after  child  last 


I  cultures  at  least  24  hours  apart  are  reported 


until  22d  day  after  child  last 


Exclude  15th  to  22d  day  after  child  last  saw  patient 


Until  se^ 
days  af 
quarant  i 


Seven  days  from  X 
child        last 
patient 


after  quaran- 
tine has  been 
raised  or  7 
days      after 


Fourteen  days  provided  no  cough  develops 


con,pktccha„g.of  clothing  (or. cta„glor™de?:rL?d°a'S?rg?Xl^^^^^^ 


Exclude  from   school 


Exclude  from  15th 
22d  day  after  child 
last  saw  patient 


Exclude  20  day; 
less  they  have  been 
successfully  vacci- 
nated within  I  year 


A  mild  disease  and  seldom  a 


Very  dangerous,  both  during  attack  and  from 
after  effects.  When  diphtheria  fx^c^^s  in  a 
school  all  children  suffering  from  sore  throat 


health  officer  should  take  cultures  from  all 


not   recognized,   but   ; 


After  effects  often  severe.  Period  of  greatest 
risk  of  infection  three  days,  before  and  after 
the  rash  appears,  Great  variation  in  type 
of  disease.  Dangerous  in  children  under  2 
years  of  age.  During  an  outbreak  all  chil- 
dren having  a  temperature  over  99''F  should 
be  sent  home  and  the  health  officer  notified. 


Disease  i 

stages.     After  effect  i 

muscle   groups,    transitory   1 

Death  is  due  usually  to  paralysis'  of  respira- 


cpmmunicable  in  the  early 
';  paralysis  of  certain 
permanent. 


Dangerous  both  during  attack  and  from  after 
effects.  Great  variation  in  type  of  disease. 
Slight  attacks  are  as  infectious  as  severe  ones. 
Many  mild  cases  not  diagnosed  and  many 
concealed.  A  second  attack  is  rare.  When 
scarlet  fever  occurs  in  a  school,  all  cases  of 
sore  throat  should  be  sent  home  and  health 
officer  notified.    Most  fatal  in  children  under 


:   of  disi 
Mild  or  modified  smallpox  is  a 

severe  type. 


suffering  from  the  disease. 


linated   by   a   patient 


Second     attack 


s  probably  suffering  fiom  whooping  cough, 
g  childre 


1  type  of  disease.     Often 


garments  out  of  doors  before  these  are  put  on  again) 


thorough  brushing  of  the  teeth;  rinsing  the  mouth;  gaigling  the  throat,  and  douching  and  spraying  the  nose  with  an  antiseptic  solution;  and  finally,  a 


DISINFECTION  AND  QUARANTINE  187 

A  committee  of  medical  advisers  of  several  private  schools  in 
New  York  City  issues  little  cards  (see  opp.  p.  188),  which  must  be 
presented  when  the  child  returns  to  school.  A  different  color  is 
used  for  each  of  the  common  communicable  diseases.  The  face 
of  the  card  is  used  for  the  attending  physician's  certificate  and  the 
back  of  the  card  for  information  relating  to  the  disease. 

Disinfection. — A  few  years  ago  our  largest  cities  were  spending 
large  sums  of  money  for  compulsory  disinfection,  which  was  re- 
quired after  most  communicable  diseases,  e.g.,  diphtheria  and  scar- 
let fever. 

The  whole  theory  of  disinfection  has  undergone  decided  changes 
in  the  last  few  years,  however.  Experiments  have  shown  that  or- 
ganisms in  the  air  tend  to  die  off  rather  quickly  under  ordinary 
conditions  (see  chapter  on  Air,  Chapter  VI,  p.  115).  Then,  too, 
it  was  found  possible  to  care  for  two  or  three  different  communicable 
diseases  in  the  same  room  without  cross  transfer,  if  the  attendants 
were  particular  about  washing  their  hands  after  attending  a  patient, 
and  before  going  to  the  next  patient.  The  hospital  at  Providence 
was  the  first  to  demonstrate  this  principle  on  a  large  scale.  The 
various  patients  may  be  separated  merely  by  low  partitions ;  and  if 
opportunities  for  washing  the  hands  are  arranged  for  each  cubicle-. 
or  compartment,  the  cases  of  cross  transfer  may  be  less  than  in. 
some  hospitals  using  separate  wards  for  the  various  diseases.  This 
indicates  that  the  organisms  do  not  live  long  enough  in  ordinary  air 
to  make  the  necessary  circuit  (over  partitions,  etc.),  but  that  the 
greatest  danger  lies  in  direct  contact. 

Such  facts  as  these  have  led  us  to  change  our  former  rulings 
concerning  disinfection.  It  is  evident  that  organisms  discharged 
by  a  patient  would  not  live  on  floors,  carpets,  walls,  etc.,  as  long  as 
they  would  continue  to  live  in  his  body.  By  the  time  the  convales- 
cent period  is  over,  relatively  few  of  the  organisms  discharged  dur- 
ing the  course  of  the  illness  are  still  alive.  In  other  words,  by  the 
time  the  patient  himself  is  a  safe  companion,  the  room  and  its  con- 
tents are  not  very  dangerous,  especially  if  the  patient's  discharges 
have  been  cared  for  properly. 

Concurrent  Disinfection. — ^That  means  that  we  must  have 
concurrent  as  well  as  terminal  disinfection.  It  is  not,  as  some 
people  think,  that  disinfection  is  no  longer  necessary;  it  is  rather 
that  continuous  disinfection  is  added  to  terminal  disinfection.    We 


188  HOME  AND  COMMUNITY  HYGIENE 

now  know  for  most  diseases  just  how  the  causal  organisms  leave  the 
body.  Everything  that  has  probably  come  in  contact  with  such 
discharges  should  be  disinfected  at  once  to  protect  other  people  and 
to  prevent  reinoculation  of  the  patient  himself.  This  will  usually 
include  dishes,  handkerchiefs,  towels,  bedding  and  thermometers. 
Consult  the  table  on  page  173  for  special  diseases.  If  the  condi- 
tions indicate  that  they  will  not  be  adequately  cared  for  outside  the 
sick  room,  the  nurse  or  attendant  should  disinfect  them  before  they 
leave  the  room.  She  should  be  careful  not  to  transfer  organisms 
on  her  hands,  washing  them  thoroughly  every  time  she  leaves  the 
sick  room.  If  this  contemporary  disinfection  has  been  thoroughly 
done,  the  terminal  disinfection  is  a  relatively  simple  matter,  and 
does  not  require  any  unusual  equipment. 

Terminal  Disinfection. — At  the  end  of  the  isolation  period  the 
patient  should  be  given  a  complete  bath  (including  mouth,  nostrils, 
and  hair),  and  dressed  in  fresh  uninfected  clothing.  The  room 
itself  should  be  given  a  thorough  cleaning,  washing  in  good  hot 
soapy  water  all  parts  that  it  is  possible  to  treat  in  this  way.  A 
fresh  coat  of  stain  or  paint,  or  fresh  wall  paper  if  the  walls  are 
papered,  is  desirable,  particularly  in  diseases  caused  by  such  re- 
sistant organisms  as  tuberculosis.  The  room  should  be  well  aired 
and  sunned.  Exposure  of  the  bedding,  rugs,  etc.,  to  direct  outdoor 
sunlight  is  part  of  thorough  terminal  disinfection ;  articles  should 
be  turned  so  that  each  side  of  every  article  is  exposed  for  two  to 
three  hours  to  strong  sunlight. 

Chemical  disinfection  of  rooms  is  still  demanded  in  most  places 
after  smallpox  and  infantile  paralysis,  because  until  we  know  more 
of  the  organisms  and  the  way  they  leave  the  body,  we  wish  to 
run  no  unnecessary  risks  (see  Appendix). 

Chemical  Disinfectants. — It  is  usually  much  more  convenient 
to  use  chemicals  as  disinfectants  than  such  natural  agents  as  heat 
and  sunlight.  These  chemicals  may  draw  all  the  water  out  of  the 
bacteria  and  so  cause  their  death ;  they  often  coagulate  the  bacterial 
substance  just  as  heat  does ;  some  chemicals  actually  dissolve  or  de- 
stroy the  cells.  The  chemicals  to  use  in  any  situation  depend  upon 
various  conditions — their  relative  cost,  their  effects  upon  other  ma- 
terials (clothing,  metal  containers),  their  poisonous  character  (if 
handled  by  children,  tracked  by  flies  upon  food),  and  the  rate  at 
which  they  spoil  or  lose  their  efficiency.     For  instance,  carbolic 


^"^^S^^J^^^^^"^^'  ^^^Y  FILLED  BY  THE  ATTENDING  PHYSICIAN.  MUST 

BE  PRESENTED  FOR  EACH  CHILD  ON  OR  BEFORE  THE  RETURN 

TO  SCHOOL  AFTER  ILLNESS  FROM  A  CONTAGIOUS  DISEASE. 


ulijia  (UtttX^tB  that 


has  fully  recovered  from  an  attack  of- 


-was  taken   ill 


and  in  my  opinion  there 


is  no  further  danger  of  the  child  carrying  contagion. 


Date- 


Aitendtng  {or  Examining)  Fb^cian. 


(OVBJi ) 


MUMPS  (INFECTIOUS  PAROTITIS) 


I.  After  ar 
turn  to  school 
the  swelling,  ai 


attack  of  this  di; 
1  one  week  after 
i  after  careful  dh 


II.  I.  a.  Pupils  of  the  . 
had  thix^^isease,  if  they  rer 
turn  to  school  during  the  ex 
til  the  twenty-second  day  al 
after  careful  disinfection. 


b.  Pupils  of  the 
disease,  if  they  rema 
immediately  provided  ine  c 
and  after  careful  disinfect! 


r.e  family,  who   have   had  this 
It  home,  may  rctym  to  school 


had  this  disease,  if  at  oi 

in  which  the  disease   ex 

fection,  return  to  school  _..   „..   .„. 

untU  the  fifteenth  day;  they  will  th 


same    family    who  ■  have    r 

■e  withdrawn  from  the  ho' 

ts,   may,  after  careful  dis 

the  third  day  and  rem: 

be  excluded  l 


til  the  twenty-second  day  after  exposure. 

b.  Pupils  of.  the  same  family  who  have  had  the. 
disease,  tf  at  once  withdrawn  from  the  home  in  which 
the  disease  exists,  may  return  to  school  immediately 
after  careful  disinfection. 

III.  o.  Children  exposed  at  school  or  elsewhere 
who  have  not  had  this  disease,  may  remain  at  school 
for  fourteen  days;  they  will  then  be  cycIudM  from 
the  fifteenth  until  the  twenty-second  day  after  ex- 
posure. 

b.  Children  exposed  at  school  or  elsewhere  "who 
have  bad  this  disease  may-return  to  school  immediately. 

»6t»:By  careful  disinfection  is  meant  a  charfge  of  cloth- 
ing  after  washing  the  entire  body  and  hair  with  soap 
and  water;  brushing  the  teeth;  and  rinsing-the  mouth 
gargling  the  throat  and  douching  or  spraying  the  nose 
with  as  antiseptic  solution. 


DISINFECTION  AND  QUARANTINE 


189 


Common  uses 


Disinfectant  or  disinfecting 
process 


Remarks 


Cuts  or  breaks  in  skin . 


Woiinds  containing  pus 

Chronic     sore     throat, 
sore  eyes 

Inflamed  or  blood-shot 

eyes 

Sore  throat 


Tooth  brushes . 


Sponge  cups,  envelope 
moisteners 


Hands 

Drinking  water 

Swimming  pool 

Room  and  contents .  . , 
Woodwork  and  floors . 


Iodine,  alcohol. 


Hydrogen    peroxide. 

Flush     until     pus     is 

.washed  out 
Silver  nitrate 


Boric  acid  (sat.  solution) 


Argyrol  (15  per  cent.)  or 
tincture  of  iron  by 
brush.  Gargle  hydro- 
gen peroxide  (J^  water) 

Drying  and  sunlight. 
Salt — dry  on  tooth 
brushes  ^ 


Thymol  1  :  1000. 


Scrub   with   green   soap 

and  hot  running  water 

BoiUng 

Hypochlorites 

Formalin 

Strong  hot  soapy  water; 

1  half-pound  cake  to  5 

quarts  of  water 


Then  wrap  in  dry  sterile 
gauze.  Alcohol  is  too 
drying  to  repeat  often. 
Once  a  day  is  enough 
for  iodine.  If  wounds 
are  re-infected  (dirty 
water,  etc.)  use  disin- 
fectant again — even  at 
risk  of  too  great  drying 


To  be  used  only  by  ex- 
perienced nurses  and 
doctors 

Good  antiseptic;  harm- 
less. Use  fresh  cups, 
etc.,  for  each  eye 

Argyrol  is  much  milder; 
iron  solutions  should 
not  come  in  contact 
with  the  teeth 

At  least  2  tooth  brushes 
should  be  kept  in  use — 
to  insure  thorough  dry- 
ing. Wet,  soggy  tooth 
brushes  should  not  be 
tolerated 

Can  be  made  inexpen- 
sively at  home  in  large 
quantities.  An  anti- 
septic only.  Hands  that 
handle  money  should  be 
washed  thoroughly  in 
soay  before  eating 


See  appendix  for  cheroi- 

cal  treatment 
See  appendix 
See  appendix 
FoUow  by   hot   soapless 

water,    if    surfaces    are 

affected  by  soap 


*  This  dried  salt  should  be  washed  off  before  using.  Too  much  salt  may 
irritate  the  gimis.  A  cup  of  salt  in  which  the  brush  can  be  twisted  around  to 
secure  a  thorough  coating  on  the  bristles  will  be  found  convenient. 


190 


HOME  AND  COMMUNITY  HYGIENE 


Common  Uses 


Disinfectant  or  disinfecting 
process 


Remarks 


Boats,  cars 


Stables 

Iirfected  bedding,  towels, 
handkerchiefs 


Formalin  (or  hot  steam 
for  hulls,  etc.) 


Mattresses,  rugs,  carpets 

Hired  or  borrowed 
clothes 


Boil  in  strong  soapy  water 


Sun  2-3  hours  on  each 

side 
Sun  as  above,  especially 

surfaces  in  contact  with 

the  body 


See  Appendix 

See  reference  in  Appendix 

To  be  sure  all  the  water 
is  equally  hot,  boil  20 
minutes  to  1  hour.  Dis- 
infectants may  be  added 
but  are  not  necessary. 
If  disinfectants  only  are 
used,  use  one  with  label 
giving  definitely  its 
strength  when  com- 
pared with  carbohc  acid 

Spread  on  grass  or  hang 
on  line  to  expose  fully 

FormaUn  may  be  used  if 
opportunity  for  sunning 
is  lacking  (see  appendix) 


acid — a  favorite  disinfectant  of  firmly  established  value,  because  it 
does  not  affect  fabrics,  even  dyed  goods,  and  acts  directly  upon 
bacteria,  even  spores,  no  matter  if  much  other  organic  matter  is 
present — is  no  longer  possible  as  a  disinfectant.  Its  price  is  nearly 
a  dozen  times  its  pre-war  price  of  eighteen  cents  a  pound.  Many 
acids  are  so  destructive  to  textiles  metals,  etc.,  that  they  cannot  be 
used  at  all. 

Argyrol  and  hydrogen  peroxide  are  two  very  valuable  aids,  but 
deteriorate  very  rapidly  and  often  give  a  false  feeling  of  security, 
especially  argyrol  which  produces  no  characteristic  sensation  by 
which  one  can  judge  its  strength. 

See  pp.  189-190  (also  i^ppendix)  for  common  uses  for  which 
one  may  require  a  disinfectant.  Many  other  disinfectants  could  be 
given,  but  the  preference  has  been  given  to  common  substances 
obtainable  at  most  drug  stores,  except  for  a  few  so  widely  known 
or  by  such  well-known  firms  that  they,  too,  can  be  easily  secured. 

Home  and  Emergency  Disinfectants. — In  general,  avoid  for 
home  use  the  disinfectants  known  to  be  poisonous.  The  risks  are 
too  great.  If  they  are  to  be  used,  have  the  druggist  add  to  such 
colorless  poisons  as  corrosive  sublimate  a  little  coloring  (such  as 
methylene  blue  or  any  other  aniline  dye).    There  is  no  reason  why 


DISINFECTION  AND  QUARANTINE  191 

poisonous  tablets  should  not,  when  manufactured,  be  slightly  tinted 
with  an  aniline  dye  to  prevent  their  being  taken  as  headache 
tablets. 

Some  disinfectants  are  valuable  for  emergencies — or  for  occa- 
sional use,  but  should  not  be  used  repeatedly.  Gasoline  is  a  dis- 
infectant usually  available  in  automobile  accidents;  turpentine  is 
another  often  used  by  workmen,  but  both  are  too  irritating  to  use 
if  better  disinfectants  can  be  secured.  Alcohol  kills  most  human- 
disease  bacteria  in  one  minute.  It  is  useful  as  a  first  wash  on  cuts 
or  bruises;  but  it  dries  the  wound  if  used  repeatedly  and  makes  it 
crack  or  heal  very  slowly. 

Patented  Disinfectants. — If  patented  disinfectants  are  used, 
see  that  they  bear  the  name  of  a  well-known  firm,  or  else  ask  your 
local  or  State  health  board  what  their  value  is.  There  are  on  the 
market  many  tooth  washes  of  no  disinfecting  value  whatever.  The 
buyer  can  to  a  great  extent  protect  himself  by  a  careful  reading  of 
the  label.  Eeputable  firms  do  not  care  to  risk  their  reputation  by 
exaggerating  the  values  of  their  disinfectants,  so  their  word  can 
usually  be  relied  upon.  They  have  expert  chemists  who  determine  ex- 
actly how  strong  a  disinfectant  is  and  their  products  state  it  plainly 
and  positively  in  one  of  two  ways :  ( 1 )  by  comparing  it  with  the 
well-known  standard,  carbolic  acid  (phenol),  saying  it  is  two  times 
as  strong,  can  be  used  one-fifth  as  strong,  etc.  If  a  preparation 
such  as  lysol  is.  more  efficient  than  carbolic,  ihej  indicate  its  in- 
creased efficiency  as  just  described,  or  say  it  has  a  coefficient  of 
3  or  6.  (2)  The  second  way  is  by  saying  clearly  it  will  kill 
such  and  such  bacteria,  mentioning  them  by  name,  and  giving  the 
time  necessary.  Cheap  or  unreliable  firms  often  advertise  Ger- 
micide or  Bactericide  in  big  letters,  but  to  avoid  prosecution  do  not 
support  it  in  either  of  these  two  ways  in  the  descriptive  matter  on 
the  bottle.  Sometimes  the  wrapper  says  "  Germicide,"  but  the 
bottle  label  merely  says  "  safe  mouth  wash,"  or  "  antiseptic  for 
wounds."  A  firm  that  hesitates  to  state  clearly  what  the  actual 
strength  is,  either  does  not  know — or  does  not  want  you  to  know.  In 
all  such  cases  take  the  simpler  unpatented  articles,  such  as  alcohol. 

Firms  often  advertise  in  concrete  (but  vague)  ways  to  catch  the 
public  eye,  "  Do  you  want  to  avoid  Riggs  disease  ?  Then  use  No- 
Rigg  tooth  paste."    Or,  "  Put  a  little  ISTo-Germ  in  the  waterbox  of 


192  HOME  AND  COMMUNITY  HYGIENE 

your  furnace  and  avoid  disease."  When  bacteria  are  put  into  strong 
solutions  of  iSTo-Eigg  paste  or  No-Germ  they  are  not  killed.  The 
advertisements  in  question  are  purposely  misleading.  If  No-Germ 
cannot  kill  bacteria  placed  directly  in  it,  how  could  it  kill  bacteria 
in  the  air  in  the  house  when  a  little  is  put  into  the  waterbox  of 
the  furnace  ? 

Heat  as  an  Aid. — Heat  increases  the  value  of  any  disinfect- 
ant, therefore  weak  disinfectants,  such  as  borax  or  salt,  are  more 
effective  as  a  gargle  if  used  in  hot  water.  (Inflammable  substances, 
like  alcohol,  should  never  be  heated  over  or  near  a  flame.) 

Soaps. — Soap  as  a  house  disinfectant  should  be  used  in  strong 
solution,  10  per  cent,  (one-half  pound  to  five  quarts  of  water),  and 
the  water  should  be  as  hot  as  possible. 

Green  soap,^  so  frequently  used,  seems  quite  valuable  as  a  hand 
disinfectant.  The  hands  are  scrubbed  with  full-strength  green  soap 
for  five  minutes.  Its  proportions  are  given,  as  its  effect  upon  the 
skin  also  tends  to  make  it  popular. 

Medicated  Soaps. — There  is  some  danger  in  using  common 
soaps  in  public  places,  especially  where  the  users  follow  in  close 
succession.  Liquid  soap  containers  should  be  provided  in  all  public 
lavatories  (including  boarding  houses) ;  these  lessen  the  chance  of 
contact  with  injurious  bacteria,  for  some  may  live  long  enough  on 
cakes  of  soap  to  be  transferred  to  other  people.  The  small  amount 
of  any  chemical  added  to  soap  is  usually  insufficient  to  affect  bac- 
teria. Take  carbolic  soap  as  an  illustration.  A  5  per  cent,  solution 
of  carbolic  acid  kills  bacteria  in  twenty  to  thirty  minutes.  No  one 
pretends  to  believe  that  any  soap  lather  or  soapy  water  contains  5 
per  cent,  of  carbolic  acid,  and  we  do  not  wash  our  hands  for  twenty 
to  thirty  minutes  at  a  time.  Some  disinfectants  have  a  cleansing 
action,  helping  to  remove  grime,  to  cut  grease,  etc.  The  common 
commercial  soaps  are  not  dependable  as  hand  or  skin  disinfectants. 
Eosenau  says  the  ordinary  medicated  soap  is  usually  a  snare  and  a 
delusion,  and  states  that  carbolic  acid,  bichloride  of  mercury  and 
many  similar  substances  may  so  comhine  with  the  soap  as  to 
decrease  their  slight  disinfecting  power. 

Exception  might  be  made  to  McClintock's  soap,  which  contains 

'  Green  soap :  10.2'  per  cent,  potash  soap,  0.8  per  cent,  olive  oil,  1 
per  cent,  glycerin,  43  per  cent,  alcohol  and  45  per  cent,  water. 


DISINFECTION  AND  QUARANTINE  193 

an  unchanged  active  mercury  salt,  and  a  1  per  cent,  solution  of 
this  soap  kills  typhoid,  diphtheria,  etc.,  in  one  minute.  It  has  the 
added  advantage  of  not  attacking  ordinary  metals  or  instruments. 
The  treatment  of  wounds  is  discussed  under  Military  Hygiene 
(p.  342). 

PROBLEMS 

1.  Give  for  some  communicable  disease  a  route  of  transfer  which  has 
come  under  your  observation. 

2.  Give  from  your  own  experience  a  blocked  route  of  transfer,  such  as 
that  shown  in  Fig.  48,  in  which  only  children  exposed  to  Dorothy  con- 
tracted the  disease.  Show  that  the  attitude  of  parents  with  regard  to 
diseases — even  children's  diseases — makes  them  valuable  or  objectionable 
members  of  a  community,  ho  matter  what  their  other  qualifications  may  be. 

3.  What  diseases  are  subject  to  quarantine  in  your  locality? 

4.  Recently,  in  a  girl's  dormitory,  a  senior  isolated  with  acute  sore 
throat  broke  her  parole  and  visited  two  friends,  both  of  whom  lat^r  con- 
tracted! a  sore  throat.  For  what  besides  their  doctor's  bill  should  the  first 
girl  have  been  held  responsible? 

5.  Write  out  a  set  of  directions  for  the  concurrent  disinfection  of 
typhoid. 

6.  Write  out  a  set  of  directions  for  terminal  disinfection  of  a  room 
occupied  by  a  tuberculosis  casej  number  the  directions  in  order  of  their 
proper  sequence. 

7.  Send  for  Reprint  436,  Public  Health  Service.  This  gives  for  38 
communicable  diseases  the  infective  agent,  source  of  infection,  mode  of  trans- 
mission, incubation  period,  period  of  communicability,  and  methods  of  con- 
trol. What  use  can  be  made  of  this  valuable  pamphlet  by  heads  of  families? 
By  school  authorities?    By  health  departments? 

8.  What  are  the  soil-borne  diseases  of  your  locality? 

See  Reference  List  at  end  of  Appendix. 


IS 


CHAPTEE  XI 
TREATMENT  AND  PREVENTION  OF  DISEASE 

,  THE  BODY  REACTIONS 

•  One  of  our  pioneer  bacteriologists  has  said,  "We  never  really 
cure  any  disease;  we  only  help  the  body  to  overcome  it."  The 
nearest  we  can  come  to  a  definite  exception  to  this  statement  is 
the  action  of  certain  chemicals,  snch  as  quinine  for  malaria,  which, 
injected  into  the  blood,  destroys  the  malaria  organisms.  But  it 
would  be  difficult  even  in  this  case  to  prove  that  the  chemicals  did 
everything  and  the  body  cells  nothing. 

Body  Reactions  to  Disease. — It  is,  therefore,  necessary  to 
imderstand  just  how  the  body  reacts  against  disease-producing  or- 
ganisms, if  we  desire  to  increase  these  reactions  in  treating  those 
ill  of  disease,  or  to  prevent  others  from  contracting  given  diseases. 

A  person  who  recovers  from  a  disease,  such  as  tuberculosis  or 
diphtheria,  does  so  because  one  or  both  of  the  following  reactions 
have  occurred:  (1)  his  white  corpuscles  have  destroyed  the  invad- 
ing organisms;  or  (2)  in  his  blood  have  accumulated  definite  sub- 
stances called  antibodies,  which  are  antagonistic  to  the  invading 
organisms.  Antibodies  act  against  these  foreign  bodies  or  organ- 
isms; therefore  the  term  antibodies.  These  substances  are  not 
definite  bodies  like  the  white  corpuscles  and  cannot  be  seen  even 
with  a  microscope.  They  are  contained  in  the  liquid  part  of  the 
blood,  and  while  they  cannot  be  shown  to  be  present  even  by  the 
microscope,  or  by  chemical  tests,  they  are  very  powerful  aids  in 
overcoming  disease.  They  may  kill  the  bacteria  or  they  may  help 
the  white  corpuscles  destroy  the  bacteria.  All  these  reactions  are 
summarized  in  the  following  diagram : 

(Increase  in  white  corpuscles  (phagocjd^es). 
f  Dissolve  bacteria  (lysins). 
Aid    the    white    corpuscles    (opsonins, 
to  disease  Formation  of  anti- j      agglutinins,  precipitins). 

bodies  which       |  Neutralize  the  bacterial  poisons  (anti- 
[      toxins). 

Lysins. — The  lysins  or  antibodies  that  dissolve  or  destroy  bac- 
teria may  be  very  powerful,  destroying  large  numbers  of  bacteria  in 
194 


TREATMENT  AND  PREVENTION  OF  DISEASE  195 

a  very  short  time.  How  remarkable  their  power  is  may  be  sur- 
mised by  what  they  can  do  under  circumstances  where  this  bac- 
tericidal action  can  be  definitely  measured.  An  early  experimenter, 
ITuttall,  mixed  a  little  rabbit's  blood  with  some  live  anthrax  bac- 
teria and  counted  the  number  of  bacteria  in  a  drop  of  that  mixture. 
Four  minutes  later  he  counted  the  bacteria  in  another  drop  of 
the  mixture  and  found  53,000  less  bacteria  than  before.  Although 
rabbit's  blood  is  remarkably  active  against  anthrax  organisms,  the 


Fig.  50. — In  the  centre  is  a  large  white  corpuscle  which  ^as.  ingested  or  swallowed  pneu- 
monia organisms. 

results  are  none  the  less  wonderful.  It  is  thought,  too,  that  such 
reactions  are  much  greater  in  the  body  itself  than  when  the  blood  is 
taken  out  into  test  tubes  for  such  tests. 

Since  blood  (or  lymph,  which  is  practically  blood — lacking  the 
red  corpuscles)  is  in  contact  with  one  or  more  surfaces  of  all  liv- 
ing cells,  it  is  easy  to  see  how  effectively  such  antibodies  may  pro- 
tect the  body. 

Action  of  White  Corpuscles. — Other  antibodies  in  the  preced- 
ing diagram  were  classified  as  aiding  the  white  corpuscles.  White 
corpuscles  alone  are  not  very  active  destructive  agents.  While 
white  corpuscles  without  the  aid  of  these  special  substances  found 
in  the  blood-serum    (G)    may  take  in  bacteria    (Fig.    50),   this 


196  HOME  AND  COMMUNITY  HYGIENE 

"  simple  engulfing  of  bacteria  is  not  necessarily  a  destructive  proc- 
ess." If  these  special  substances  or  antibodies  are  present  in  the 
blood-serum,  they  increase  the  rate  at  which  the  corpuscles  take  in 
and  destroy  bacteria  (phagocytosis). 

All  this  can  be  demonstrated  by  the  microscope.  If  white  cor- 
puscles and  tuberculosis  bacteria  are  mixed  together,  the  corpuscles 
will  take  in  a  certain  number  of  bacteria  (Fig.  50).  If  a  little 
serum  is  added  to  the  mixture,  the  white  corpuscles  show  decidedly 
greater  power;  not  only  do  they  engulf  the  bacteria  more  readily, 
but  they  destroy  larger  numbers  of  those  engulfed.  If  the  serum 
added  is  that  of  a  person  who  has  recovered  or  is  recovering  from 
tuberculosis,  the  white  corpuscles  show  still  greater  power,  because 
that  person  had  evidently  accumulated  a  large  amount  of  these 
special  antibodies  which  affect  the  bacteria,  and  prepare  them  for 
the  white  corpuscle  action.     Such  substances  are  called  opsonins.^ 

More  is  heard  about  the  opsonins  in  connection  with  tuber- 
culosis than  in  any  other  disease.  It  was  at  one  time  hoped  that 
we  could  tell  the  patient's  condition  and  progress  by  determining 
from  time  to  time  the  number  of  bacteria  taken  up  by  white  cor- 
puscles when  his  serum  was  added,  as  described  above,  measuring 
the  opsonic  power  of  his  blood  serum.  But  it  is  so  difficult  to  meas- 
ure accurately  the  amount  of  opsonin  present  that  little  is  now 
attempted  along  that  line.  It  is  important  to  realize,  however,  that 
this  does  not  mean  that  the  opsonins  are  thought  to  be  unimportant 
aids.  On  the  contrary,  the  phagocytic  action  of  the  white  cor- 
puscles depends  upon  these  antisubstances. 

Agglutinins. — Sometimes  the  antibodies  which  aid  the  white 
corpuscles  may  be  even  more  strikingly  demonstrated  by  means  of 
the  microscope.  If  the  serum  of  a  person  who  has  had  typhoid 
fever  be  added  to  a  drop  of  blood  containing  living  typhoid  organ- 
isms, these  actively  motile  bacteria  slow  their  movement  and  finally 
come  to  rest  sticking  together  in  groups  or  clumps,  often  several 
dozen  in  a  clump  (see  p.  215  and  Figs.  60  and  61).  This  clumping 
is  just  what  would  result  if  they  had  become  sticky  or  glutinous, 
and  we  therefore  say  they  have  agglutinated. 

^  Like  opsonium,  a  little-used  word  from  the  Greek,  which  is  used  for  any- 
thing eaten  as  a  relish,  such  as  olives  or  anchovies.  The  term  opsonins, 
therefore,  implies  that  these  substances  are  like  relishes,  making  the  bacteria 
more  attractive  to  the  white  corpuscles. 


TREATMENT  AND  PREVENTION  OF  DISEASE 


197 


It  has  recently  been  shown  that  this  same  clumping  or  agglutina- 
tion takes  place  in  the  body  as  well  as  in  drops  of  serum  observed 
under  the  microscope.  Such  clumping  is  the  result  of  a  protec- 
tive antibody  formed  by  the  body  against  the  bacteria,  and  favors 
their  destruction  by  the  white  corpuscles  (Fig.  51).  It  suggests 
the  old  recipe  for  cooking  hares,  which  began :  "  First  catch  your 
hare/'  for  these  clumped  or  agglutinated  bacteria  are  more  easily 
caught  and  engulfed  by  the  white  corpuscles.    Motile  bacteria  lose 


Fig.  51. — A  rabbit  made  immune  to  typhoid  by  earlier  injections  of  Bacillus  typhosus 
was  later  given  a  heavy  injection  of  the  same  organism.  The  left  photograph  of  blood 
taken  from  the  heart  30  seconds  later  shows  clumps  of  bacilli  and  indicates  how  rapidly 
agglutination  took  place.  The  agglutinated  cocci  (right  photograph)  were  from  a  rabbit 
immunized  against  the  pneumococcus  (causal  organism  of  pneumonia)  and  injected  similarly 
with  pneumococci. 

their  power  of  movement ;  the  large  clumps  stick  to  the  walls  of  the 
blood-vessels,  or  are  delayed  in  the  smaller  capillaries ;  they  are  held 
back  in  such  glands  as  the  lymph  "nodes''  (G),  and  so  are  more 
promptly  disposed  of  by  the  white  corpuscles. 

It  has  been  suspected  for  some  time  that  this  agglutination  was 
one  of  the  aids  against  bacterial  invasion,  but  it  was  not  supported 
by  proof  until  Bull  showed  that  this  agglutination  is  a  very  prompt 
reaction  of  the  body,  and  that  the  bacteria  are  agglutinated,  en- 
gulfed by  white  corpuscles,  and  destroyed  in  a  very  short  time,  so 
short  a  time  that  it  had  therefore  been  missed  entirely  by  other 


198  nOME  AND  COMMUNITY  HYGIENE 

investigators.  If  live  tj^phoid  bacteria  are  injected  into  the  blood 
of  an  animal  which  has  had  typhoid  fever,  blood  drawn  one  to  two 
minutes  later  from  the  heart  or  other  organs  will  be  found  to  con- 
tain agglutinated  clumps  of  bacteria  and  white  corpuscles  which 
are  already  gorged  with  bacteria,  often  dozens  in  a  single  white 
corpuscle.  The  reason  this  agglutination  was  not  observed  by 
earlier  investigators  in  such  experiments  was  that  they  looked  too 
late,  after  the  bacteria  had  been  agglutinated  and  the  white  cor- 
puscles had  already  destroyed  most  of  them.  Another  surprising 
thing  is  the  strength  of  this  antibody,  the  agglutinin.  A  horse  in- 
jected with  typhoid  bacteria,  until  he  has  become  immune  to 
typhoid,  may  accumulate  a  very  powerful  agglutinin.  An  agglu- 
tinin recently  tested  at  Eockefeller  Institute  was  so  strong  that  one 
drop  of  such  horse  blood  agglutinated  many  billions  of  typhoid 
bacteria,  all  that  could  be  grown  on  four  agar  tubes. 

In  some  cases  these  agglutinating  substances  work  in  such  a 
way  that  the  collected  clumps  of  bacteria  are  large  enough  to  be  seen 
with  the  naked  eye.  If  a  horse  has  glanders,  his  blood-serum  con- 
tains substances  which  will  clump  or  agglutinate  glanders  bacteria 
when  they  are  added  to  the  horse's  serum  in  a  test  tube.  The 
clumped  bacteria  are  gathered  together  into  a  little  rounded  ball  in 
the  bottom  of  the  test  tube,  not  at  all  in  the  way  gravity  would 
cause  them  to  settle.  Usually,  too,  the  rate  at  which  they  are  so 
precipitated  is  very  much  quicker  than  in  the  case  of  gravity.  It 
is  thought  that  these  precipitating  substances  are  really  the  same  as 
the  agglutinins,  and  that  they  act  in  the  same  way  in  the  body,  but 
differ  only  in  that  they  are  demonstrated  better  in  test  tubes  than 
by  the  microscope. 

Antitoxins. — The  antitoxins  are  another  very  important  class 
of  antibodies.  They  differ  from  all  we  have  discussed  in  that  they 
do  not  affect  the  bacteria  directly,  but  simply  neutralize  the  poisons 
(toxins)  which  the  bacteria  make;  therefore,  antitoxins.  In  a  few 
diseases,  such  as  diphtheria,  antitoxins  are  the  most  important  aids 
in  overcoming  the  disease.  Even  when  the  bacteria  are  quite  local- 
ized and  not  distributed  generally  through  the  body,  the  toxins 
formed  by  the  bacteria  may  be  rapidly  distributed  to  all  parts  of 
the  body.  For  example,  in  diphtheria  (Fig.  7),  the  organisms  are 
usually  located  in  small  patches  in  the  throat,  but  the  poisons  these 
bacteria  make  are  absorbed  by  the  blood  and  distributed  to  all  parts 


TREATMENT  AND  PREVENTION  OF  DISEASE  199 

of  the  body;  and  we  have  as  a  result  general  irritation  and  dis- 
turbance of  many  different  parts  of  the  body :  headache,  backache, 
nausea,  fever,  as  well  as  the  sore  throat  one  would  naturally  expect. 
If  a  person  is  to  recover  from  diphtheria,  he  must  not  only  kill  ofE 
the  diphtheria  organisms  in  his  bod}^,  but  he  must  also  neutralize 
or  make  ineffective  the  poisons  they  have  formed.  Antitoxins  are 
the  most  important  protective  agents  or  antibodies  against  diph- 
theria and  tetanus  (lockjaw)  and  probably  against  the  ga:s  gangrene 
bacillus  also. 

It  is  not  thought  that  any  one  of  the  antibodies  works  singly  or 
exclusively  in  any  disease.  The  serum  contains  more  than  one  anti- 
body, usually ;  for  example,  while  antitoxin  is  the  most  helpful  agent 
in  aiding  against  diphtheria,  the  serum  has  at  the  same  time  some 
bactericidal  power,  and  the  white  corpuscles  are  also  helping  to 
destroy  the  organisms.  One  of  the  hottest  arguments  in  the  history 
of  bacteriology  was  about  the  relative  importance  of  these  protec- 
tive substances.  Metchnikoff,  working  on  tuberculosis,  where  pha- 
gocytosis is  the  most  important  protective  factor,  claimed  that  re- 
covery from  disease  was  due  to  the  action  of  white  corpuscles. 
Behring,  working  on  diphtheria,  claimed  that  recovery  was  due  to 
the  action  of  the  antitoxin.  Each  worker  verified  his  own  findings, 
Metchnikoff  for  tuberculosis,  and  Behring  for  diphtheria,  and  pre- 
sented still  stronger  arguments  for  his  own  side.  If  each  had 
worked  with  the  other's  material,  he  would  have  seen  at  once  that 
the  other  was  also  right.  It  was  another  case  of  the  two  Imights 
and  the  two  sides  of  the  shield. 

Immunity  Following  Disease. — The  antibodies  which  are 
formed  by  our  bodies  to  protect  us  against  invading  bacteria  are 
usually  produced  in  excess  of  what  is  actually  necessary,  and  so  they 
may  be  found  in  the  body  a  long  time  after  the  bacteria  have  all 
disappeared.  This  is  illustrated  by  the  following  diagram  (Fig.  52). 

The  organisms  causing  a  given  disease  enter  the  body  and  begin 
to  develop  at  the  time  represented  by  a.  The  body  reaction  begins 
a  short  time  afterward  at  &.  The  multiplication  of  the  bacteria 
and  the  increase  in  antisubstances  are  represented  by  the  rising 
lines  a-c  and  h-d  respectively.  These  two  processes  run  a  race,  as 
it  were,  and  finally  at  c  the  antisubstances  begin  to  be  found  in 
excess,  and  this  overproduction  continues  for  a  time  to  d;  but  from  c 
the  bacteria  have  been  decreasing  and,  finally,  there  comes  a  time. 


200 


HOME  AND  COMMUNITY  HYGIENE 


e,  when  there  are  none  of  them  left  in  the  body.  The  antisub- 
stances,  however,  may  persist  for  some  time:  weeks,  years,  or 
throughout  life.  They  usually  persist  a  long  time  after  smallpox, 
but  a  very  short  time  after  common  colds,  etc.  The  time  from 
e  to  f  represents  the  time  between  the  end  of  one  attack  and  the 
pojnt  at  which  the  individual  might  come  down  with  another  attack 
of  the  same  disease.  In  other  words,  e  to  f  represents  the  immune 
period  following  the  recovery  from  a  given  disease. 


j 

_!•_ _                    ,                              „ti     L J         _                .X J  • 

.Z;Z2I'  "^273    ZlllZiZ^    I.    3  lE^nz^rggCI'     Ef    ulXii^j^a.  _iiT it  ^Zlll' 

^^  1--^^       ~*hL    ^;L  , 

Z£^E,?5    CT      ,  7E    27^75    I 

*   .   '* 

,35i    "^      '                          "                      '                 ' 

--                                          ^'^^^      ^                                                                      - 

^*    ^     ^^ 

i'     ir_,_  ^s      V.                 -                 -          - 

^2         •         N>    \. 

^C         -u^       -^^      ^                             -          - 

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^^  -              'It:             i     ^. 

^^  /                           •      '                           s 

^■^  ■'                 _, ^                  "'v     ^v 

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^^  "                ■    "'"li:                      ''^      "~^ 

^^    '                       -^^                          '^■^ 

'»   ^''    v"                                 X~^                                     ""^                  "-•  - 

|^_E^ li-^ b^ -^.,,£ 

Fig.  52. — Diagram  with  a  black  line  representing  the  development  of  bacteria  in 
disease,  and  a  broken  line  representing  the  lormation  of  protective  substances  (white 
porpuscles,  antibodies).  A  to  B  represents  the  incubation  period;  EtoF  represents  the 
immune  period  following  recovery.     (See  p.  199.) 

"  Natural  Immunity." — Sometimes  a  person's  blood  contains 
some  of  these  antisubstances  or  immune  bodies,  even  though  there 
is  no  record  of  his  having  had  the  diseases  in  question.  We  some- 
times speak  of  these  people  as  naturally  immune;  that  may  be  the 
correct  explanation,  but  it  is  very  possible  many  of  these  "  naturally 
immune  "  people  have  really  had  an  earlier  attack  of  disease.  There 
are  so  many  cases  that  are  difficult  to  diagnose — ^non-typical  cases — 
as  well  as  so  many  slight  cases  which  may  not  demand  the  services 
of  a  physician,  that,  we  can  never  be  sure  how  many  of  these 
naturally  immune  people  are  really  "missed  cases." 

In  a  few  cases  it  is  quite  possible  that  "natural  immunity" 
may  be  related  to  the  illness  of  the  mother  a  short  time  before  the 
birth  of  the  child ;  in  such  cases  the  child  may  have  had  the  disease 


TREATMENT  AND  PREVENTION  OF  DISEASE  201 

at  the  same  time,  or  antibodies  in  the  blood  of  the  mother  may  have 
been  transferred  to  the  child. 

Other  Types  of  Immunity. — Other  types  of  immunity  have 
been  described,  such  as  racial  and  age  immunities;  negroes  seem 
less  susceptible  to  yellow  fever,  children  are  more  susceptible  to 
whooping  cough,  measles,  or  scarlet  fever  than  adults  (Fig.  53). 
Sometimes  racial  immunity  resolves  itself  into  tolerance,  and  people 
who  think  themselves  immune  to  malaria  are  sometimes  surprised 
when  the  organisms  are  shown  to  be  present  in  their  blood.  This 
means  that  they  are  not  really  immune  to  the  disease  in  question, 

necrccLUf.    i-n    si^sr  o  ptihillis/    tff    di.nfiirhfl.ri'.rx. 

,^0^0  so  "io  7.5  % 

Fig.  53. — Diagram  showing  relative  susceptibility  of  children  and  adults  to  diphtheria. 
(From  data  in  Health  News) 

but  that  they  can  tolerate  the  organisms.  The  relative  immunity  of 
adults  is  often  traced  to  "  missed  "  or  forgotten  cases  in  childhood ; 
children,  too,  come  into  closer  contact  with  each  other  and  are  less 
particular  about  handling  things  in  a  sanitary  way,  which  also  helps 
account  for  the  so-called  partial  "  immunity  of  adults "  to  chil- 
dren's diseases :  so  that  all  statements  regarding  immunity  must 
be  weighed  carefully  before  acceptance.  Eacial  or  other  predisposi- 
tion to  disease  often  resolves  itself  into  increased  opportunities  for 
infection,  lessened  resistance  because  of  unsanitary  homes  or  in- 
sufficient food,  etc. 

Predisposing  Factors. — Hunger,  worry,  alcoholic  excess,  over- 
work, and  overexposure  are  predisposing  factors  to  disease;  for  ex- 


202  HOME  AND  COMMUNITY  HYGIENE 

ample,  chickens  are  quite  immune  to  tetanus,  but  it  has  been  shown 
by  experiment  that  if  a  chicken  is  chilled,  it  succumbs  to  the  in- 
oculation of  a  small  amount  that  otherwise  would  not  affect  it. 

TREATMENT  AND  PREVENTION 

i  In  the  preceding  paragraphs  we  have  spoken  as  if  recovery  al- 
ways followed  an  attack  of  any  disease — as  if  the  white  corpuscles 
and  the  antibodies  always  increased  at  a  sufficiently  rapid  rate  to 
prevent  a  deadly  accumulation  of  bacteria  and  their  toxins.  Un- 
fortunately, this  is  not  true,  and  bacteria  and  their  irritating  prod- 
ucts often  multiply  much  more  rapidly  than  the  body  can  provide 
protection  by  the  formation  of  extra  white  corpuscles,  antitoxins, 
agglutinins,  etc. 

If,  in  our  diagram,  the  line  h-d  never  crossed  the  line  a^c,  the 
bacteria  would  continue  to  multiply  indefinitely,  and  death  would 
finally  ensue.  The  length  and  severity  of  the  illness  would  depend 
upon  how  nearly  the  reaction  or  antibody  line  approached  and  fol- 
lowed the  bacteria  line. 

Chronic  cases  belong  here;  their  body  reactions  always  lagging 
behind  what  is  necessary  to  destroy  all  the  bacteria. 

Methods  of  Aiding  the  Individual. — It  is  now  known  that  it 
is  possible  to  help  the  individuals  who  are  too  slow  in  forming  these 
protecting  substances.  "We  can  do  it  in  three  different  ways:  (1) 
by  giving  them  drugs  or  chemical  agents  which  will  kill  the  bac- 
teria; (2)  by  stimulating  the  body  cells  to  form  the  antisubstances 
more  abundantly;  and  (3)  by  giving  the  individual  antisubstances 
made  in  the  body  of  another  animal.  We  will  discuss  these  three 
methods  separately. 

Chemical  Agents. — We  are  somewhat  limited  in  the  means  we 
can  employ  in  the  first  way,  for  while  there  are  many  chemical 
agents  which  could  be  used  to  kill  the  bacteria,  there  are  not  many 
that  could  be  used  in  sufficient  strength  without  destroying  the  sur- 
rounding tissues  or  irritating  them  so  that  they  do  not  heal  properly. 
For  example,  strong  acids  cannot  be  used  to  disinfect  wounds ;  and 
while  such  irritating  chemicals  as  carbolic  acid  and  turpentine  are 
sometimes  used,  they  are  used  very  sparingly  or  in  very  weak  dilu- 
tions. Eadium  is  another  chemical  agent  which  has  serious  attend- 
ing dangers,  as  shown  by  the  "  radium  burns  "  experienced  by  doc- 
tors and  radium  handlers.     These  "  burns  "  often  refuse  to  heal. 


TREATMENT  AND  PREVENTION  OF  DISEASE 


203 


even  with  the  best  treatment  science  affords.     It  is,  therefore,  con 
ceivable  that  the  radium  treatment  of  diseased  tissue  {e.g.,  cancer 
might  injure  the  body  cells  before  it  affected  the  cause  of  tha  dis- 
ease.   Below  are  listed  the  diseases  most  commonly  treated  by  drugs 
or  chemicals: 


Disease 

Drug  or  chemical 

Remarks 

Malaria 

Syphilis 

Wounds 

Quinine 

"Salvarsan" 

A  trade  name  for  an  arsenic- 

Aniline  dyes  (gentian  violet, 
methylene  blue) 

benzol     compound.       Other 
related  drugs  are  in  use  for 
advanced  or  severe  cases 

See  table  p.   189    for   iodine, 
alcohol,  and  other  chemicals 

Stimulating  Body  Reactions  by  Killed  Organisms, — There 
are  several  ways  of  stimulating  the  body  cells  to  form  protective 
antibodies;  these  methods  are  all  alike  in  that  they  use  dis- 
ease organisms  which  are  greatly  weakened  or  killed  before  they  are 
injected  into  the  human  body.  In  typhoid,  for  example,  a  known 
amount  of  killed  typhoid  bacteria  is  injected  into  the  flesh,  usually 
about  1  or  2  c.c,  containing  usually  one-half  to  two  billion  bac- 
teria. These  bacterial  substances  are  absorbed  by  the  blood,  and 
stimulate  the  formation  of  the  same  antibodies  as  would  typhoid 
entering  the  body  in  food,  water,  etc.  Usually  three  such  injections 
are  given  (at  intervals  of  a  few  days)  to  make  sure  that  the  indi- 
vidual forms  enough  antibodies  to  last  for  some  time,  usually  two 
to  three  years  at  least.  Eecently,  in  the  United  States  army  a  spe- 
cial glycerin  combination  of  three  disease  organisms  has  been  given, 
all  in  one  injection,  and  with  good  results      (see  pp.  211  and  338). 

Live  organisms  have  been  advocated  for  typhoid  protection,  but 
since  typhoid  may  persist  in  the  intestine  and  make  people  "  typhoid 
carriers,"  this  seems  a  very  unwise  procedure. 

Protection  by  Weakened  Organisms. — The  earliest  use  of 
weakened  organisms  to  prevent  disease  was  in  connection  with 
smallpox,  which  was  formerly  very  common;  as  late  as  1750-1780, 
in  England,  France  and  Italy,  less  than  ten  people  in  every  hun- 
dred escaped  smallpox.     Lady  Mary  Wortley  Montagu,  in  1718, 


204  HOME  AND  COMMUNITY  HYGIENE 

introduced  into  England,  after  trial  in  her  own  family,  a  method 
she  found  in  practice  in  Turkey.  Pus  from  an  eruption  on  a 
"light  case"  was  inoculated  into  the  blood  of  a  person  who  had 
not  had  smallpox,  thus  making  it  quite  probable  (though  not  at  all 
certain)  that  the  inoculated  person  would  have  a  similarly  light 
case.  This  practice  was  quite  generally  adopted  in  the  United 
States  as  well  as  England,  and  as  late  as  our  own  Civil  War  was 
used  to  prevent  smallpox.  The  people  of  Eichmond,  by  a  house-to- 
house  canvass,  were  besought  to  have  their  children  inoculated ;  the 
scabs  were  collected  and  used  to  inoculate  soldiers  in  the  Confed- 
erate army. 

A  better  method  of  securing  weaker  smallpox  organisms  was 
even  at  that  time  in  use  in  England.  Jesty,  a  farmer,  and  Jenner, 
a  physician,  knowing  the  belief  of  dairy  workers  that  people  who 
had  cowpox  did  not  take  smallpox,  performed  experiments  which 
proved  the  accuracy  of  such  beliefs.  Jesty  inoculated  his  wife  and 
two  children  with  cowpox  successfully.  Jenner  tested  more  directly 
whether  cowpox  could  protect  against  smallpox  by  inoculating  with 
smallpox  pus  ten  people  who  had  had  cowpox.  ISTot  one  contracted 
smallpox,  though  twenty  to  fifty  years  had  passed  since  five  of  the 
number  had  had  cowpox.  Jenner  added  one  more  experiment,  in- 
oculating a  boy  with  pus  from  a  dairymaid  who,  through  a  cut  in 
her  hand,  had  contracted  cowpox  from  a  cow  she  milked.  This 
cow  pus  "  took  " ;  twice  afterward  Jenner  inoculated  the  boy  with 
smallpox  pus,  but  the  boy  was  immune.  The  material  taken  from 
the  cow  was  called  vaccine  {vacca,  a  cow),  and  the  process,  vaccina- 
tion. Inoculation  of  smallpox  pus  from  human  beings  soon  decreased 
as  vaccination  was  very  much  safer,  and  gave  a  much  milder  form 
of  the  disease,  because  the  organisms  of  smallpox  had  been  weak- 
ened by  their  period  of  growth  in  the  cow.^  About  forty  years 
afterward  (1840)  the  newer  method  had  so  gained  in  favor,  that 
the  English  government  forbade  immunizing  people  by  small- 
pox pus. 

Other  Methods  of  Attenuating  Organisms. — Organisms  that 
cause  disease  may  be  attenuated  or  weakened  in  other  ways  besides 
growing  them  in  less  susceptible  animals.    If  bacteria  are  grown  in 

*  There  is  little  doubt  that  cowpox  is  really  a  forin  of  smallpox  con- 
traeted  bv  cows  from  Iniman  beings. 


TREATMENT  AND  PREVENTION  OF  DISEASE  205 

the  presence  of  weak  chemicals,  subjected  to  too  high  or  too  low  a 
temperature,  dried,  or  simply  allowed  to  grow  old,  they  may  be- 
come similarly  attenuated.  Pasteur  used  drying  to  attenuate  the 
rabies  organisms  which  are  found  in  the  brain  and  spinal  cord  of 
rabid  animals.  The  methods  generally  used  to-day  are  practically 
his  methods.  The  spinal  cord  of  a  rabid  animal  is  cut  into  little 
segments,  and  the  pieces  are  dried  to  various  degrees  of  dryness.  The 
pieces  dried  longest  contain,  of  course,  the  weakest  organisms.  The 
weakest  segments  are  ground  up  into  a  fine  emulsion  and  injected 
into  the  body  of  the  person  who  has  been  bitten.  His  body  cells 
react  to  those  weak  organisms,  forming  the  r.ecessary  antibodies. 
This  is  repeated  with'  stronger  and  stronger  organisms  (cord  seg- 
ments dried  for  shorter  periods  of  time),  until  almost  full  strength 
organisms  are  given — dried  for  but  three  days,  or  even  but  one 
day. 

Rabies  organisms  develop  slowly;  the  repeated  injections  of  or- 
ganisms of  increasing  virulence  call  forth  greater  and  greater  num- 
bers of  antibodies,  until  the  body  is  fully  protected  against  all  the 
results  that  could  have  come  from  the  organisms  left  in  the  body 
when  bitten  by  the  dog.  It  is  interesting  to  know  Pasteur  tried 
this  treatment  on  fifty  dogs  with  success,  but  even  then  could  not 
by  the  laws  of  France  try  it  on  a  human  being.  Finally  he  was 
allowed  to  treat  an  unfortunate  individual  for  whom  there  seemed 
no  hope,  as  he  was  badly  bitten — in  fourteen  places — and  vindicated 
his  theory. 

The  Term  "  Vaccine." — The  term  vaccine,  as  we  have  seen, 
was  first  used  for  live  but  weakened  organisms  obtained  from  a 
living  animal^  the  cow.  Most  vaccines,  as  the  term  is  now  used, 
are  not  produced  in  living  animals  at  all,  but  are  grown  in  tubes 
or  flasks  of  broth  in  the  laboratory;  in  treatment,  some  of  these 
broth  growths  or  cultures  are  weakened  by  chemicals,  unfavorable 
temperatures,  etc.,  but  most  of  them  are  actually  killed  before  they 
are  used. 

Killed  Organisms. — For  vaccines  made  of  these  killed  bacteria, 
some  authorities  use  the  word  tacterin,  reserving  vaccine  for  living 
organisms.  This  distinction,  however,  is  not  generally  made,  and 
the  use  of  the  term  vaccine  for  the  killed  cultures  so  widely  used 
in  the  recent  European  war  will  make  it  impossible  ever  to  restrict 
the  word  vaccine  to  its  original  meaning. 


206  HOME  AND  COMMUNITY  HYGIENE 

The  bacteria  used  in  making  all  vaccines  are  taken  originally 
from  disieased  tissues  and  kept  alive  on  such  media  as  broth  and 
gelatin.  Sometimes  they  lose  their  virulence  in  long-continued  cul- 
tivation on  artificial  media,  but  that  does  not  always  happen;  for 
iiLstance,  the  strain  of  diphtheria  now  in  use  in  almost  all  parts  of 
tlJe  world  for  making  antitoxins  was  isolated  years  ago  by  the  New 
York  City  Board  of  Health,  and  it  seems  even  mare  virulent  than 
when  originally  isolated. 

There  are  various  types  or  varieties  of  most  disease  organisms. 
The  vaccine  provided  by  any  laboratory  is  often  not  made  from  the 
special  variety  infecting  a  given  individual,  and,  therefore,  not  quite 
so  helpful  to  him  as  if  made  from  his  own  particular  type.  It  can 
be  secured  by  taking  material  (bluod,  pus,  etc.)  from  the  infected 
area  and  getting  from  it  the  organism  responsible  for  the  trouble. 
This  organism  may  then  be  grown  in  broth,  etc.,  and  used  as  a 
vaccine.  Such  vaccines  are  called  autogenous  vaccines.  In  serious 
or  quickly  developing  illness  there  is  not  time  to  wait  for  the 
making  of  autogenous  vaccines,  as  it  takes  at  least  two  to  four 
days ;  but  it  is  often  done  in  treating  slow  or  chronic  diseases,  such 
as  persistent  boils,  especially  if  the  patient  does  not  respond  to  the 
types  of  vaccine  in  general  use. 

Dosage. — The  dosage  varies  greatly,  depending  upon  the  phy- 
sician's diagnosis,  the  period  through  which  the  doses  are  given, 
etc.  The  following  figures  indicate  the  wide  range:  typhoid,  2 
million  to  10  billion;  influenza,  10  to  500  million;  streptococcus,  5 
to  500  million;  staphjdococcus  (for  boils,  etc.),  100  to  1000  million. 

Antitoxins. — Some  bacteria  make  large  amounts  of  toxins 
which,  being  soluble,  are  found  in  the  broth  in  which  the  bacteria 
are  grown.  If  this  broth  is  filtered,  the  material  passing  through 
the  filter  (the  filtrate)  contains  these  soluble  toxins.  If  this  toxin- 
containing  filtrate  is  used  for  inoeiilation  the  person  or  animal  reacts, 
forming  antibodies  about  as  he  would  if  the  bacteria  had  not  been  fil- 
tered out.^  The  antibodies  thus  formed  are  called  antitoxins. 

The  most  recent  method  of  preventing  diphtheria  in  young 
children  is  based  upon  the  stimulation  of  body  reactions  by  such 

^  This  is,  whenever  possible,  a  preferable  method,  as  it  means  injecting 
less  foreign  material.  Foreign  material  is  always  irritating,  and  even 
sterile  substances,  such  as  white  of  egg,  not  in  themselves  poisonous,  may 
cause  irritation,  abscesses,  fever,  and  even  death  when  injected  into  animals 
in  appropriate  amounts  and  at  certain  intervals. 


TREAT^IENT  AND  PREVENTION  OF  DISEASE  207 

toxins.  They  are  now  inoculated  with  a  modified  diphtheria  toxin 
to  cause  them  to  produce  sufficient  antitoxin  to  protect  tliem 
against  diphtheria  during  the  susceptible  jDeriod  of  childhood. 

Even  in  diseases  contracted  naturally  we  do  not,  unfortunately, 
always  react  with  sufficient  promptness  to  prevent  serious  illness  or 
death.  It  often  happens,  also,  that  many  individuals  do  not  re- 
spond sufficiently  even  when  they  are  also  stimulated  by  such  sub- 
stances as  vaccines  and  toxins.  Such  cases  may  be  aided  b}'  giving 
them  the  reacting  substances  formed  by  another  person  or  animal 
and  present  in  the  blood  of  that  person  or  animal  (Fig.  54),  In 
the  recent  infantile  paralysis  epidemic  an  attempt  (on  a  small 
scale)  was  made  to  protect  affected  children  by  injecting  blood 
from  persons  who  had  recovered  from  infantile  paralysis. 

It  is  difficult  to  secure  sufficient  amounts  of  such  immune  blood, 
and,  when  possible,  animals  are  substituted.  Horses  are  commonly 
used  for  securing  such  substances,  as  they  are  clean  animals,  free 
from  most  of  the  diseases  that  might  affect  man ;  and  because  it  is 
possible  to  draw  at  one  time  sufficient  blood — ^usually  eight  to  twelve 
quarts — to  make  it  worth  while  commercially.  Antitoxins  for  diph- 
theria, tetanus,  and  for  the  gas  gangrene  infections  are  secured  by 
injecting  horses  with  the  toxins  of  the  respective  organisms.  This 
is  not  done,  of  course,  to  protect  the  horses,  as  they  do  not  often 
have  these  diseases,  but  so  that  we  may  use  their  blood  in  treating 
human  cases.  Whole  blood  from  such  immune  animals  is  rarely 
used,  as  practically  all  the  antibodies  are  in  the  serwn.^  Instead, 
we  eliminate  the  corpuscles,  fibrin,  etc.,  including  many  blood  pro- 
teins (by  chemical  treatment,  filtering,  etc.)  ;  the  modified  serum 
left  still  has  high  protecting  qualitiesi.  Such  modified  iserum  is 
called  by  the  name  of  the  protective  substance  or  antibody  most 
prominent  or  most  desired,  e.g.,  antitoxin.  It  is  essentially  the  same 
substance  whether  produced  in  the  human  body  or  in  the  body  of  an- 
other animal.  "We  "  give  antitoxin  "  from  horses  in  treating  human 
cases  because  the  human  being  is  not  himself  forming  enough  anti- 
toxin to  protect  himself.  Sometimes  this  modified  serum,  as  de- 
scribed above,  loses  a  great  part  of  its  desired  substances,  and  the 
whole  serum  is  used.    Tetanus  antitoxin  and  gas  bacillus  antitoxin 

*  Just  as  toxins  may  be  less  irritatinoc  than  the  bacteria  themselves, 
so  serum,  too,  may  be  less  irritating  than  the  whole  plasma  or  liquid  part 
of  the  blood.  Our  present  refined  antitoxins,  for  example,  do  not  produce 
the  rashes  formerly  produced  when  whole  serum  was  used  for  diphtheria. 


208 


HOME  AND  COMMUNITY  HYGIENE 


are  practically  sera;  their  antitoxic  qualities  are  so  marked,  how- 
ever, that  they  are,  nevertheless,  called  antitoxins. 


BBS     '87      1W      '91       '93       '9S    '97  (900     '02     '04      '06      '08      'W       "tt      '14 

Thirty  Yeajis  op  Dipbtheeia  in  New  York  State 
Fig.  54. — The  effect  of  antitoxin  on  the  diphtheria  death  rate  is  shown  by  this  graph. 

The  tahle  on  page  211  describes  briefly  a  few  of  the  protective 

substances  in  common  use.  Most  substances  of  this  kind  are  injected 
into  the  tissues  just  beneath  the  skin  (subcutaneously)  ;  they  act 
more  quickly  if  injected  into  a  vein  (intravenously,  Fig.  55)  ;  in 


TREATMENT  AND  PREVENTION  OF  DISEASE 


209 


diseases  aifecting  the  nervous  system  and  adjacent  tissues  they  are 
preferably  injected  directly  into  the  spinal  canal  (intraspinally, 
iFig.  56). 

It  is  thought  that  the  immune  substances,  agglutinins,  anti- 
toxins, etc.,  are  produced  mainly  in  tissues  forming  the  blood-cells : 
the  bone  marrow,  the  spleen,  and  the  lymph-nodes.     In  some  cases 


Fig.  55. — a.  Intravenous  injection  of  drugs,  serum,  etc.,  is  done  as  shown  here.  '  In 
subcutaneous  injection  no  eSort  is  made  to  strike  a  blood-vessel,  b.  Syringe  used  in  such 
injections. 

antibodies  seem  to  be  formed  also  by  tissues  near  the  site  of  irrita- 
tion or  injury,  e.g.,  the  lung  area.  The  white  corpuscles  them- 
selves may  be  a  source  of  some  of  these  immune  bodies. 

Immunity  to  disease  as  described  in  the  preceding  pages  may  be 

either  active  or  passive.     When  quinine  is  given  in  daily  or  less 

frequent  doses  in  malaria,  the  immunity  gained  is  passive,  and  due 

to  the  quinine  and  not  necessarily  to  any  activity  on  the  patient's 

14 


210 


HOME  AND  COMMUNITY  HYGIENE 


part.  The  same  is  true  when  serum  or  antitoxin  is  given.  But 
when  the  bacteria  or  their  products  are  given,  they  stimulate  the 
individual  to  produce  protecting  substances.  Such  immunity  is  as 
truly  active  immunity  as  that  gained  when  an  individual  contracts 
the  disease  "  naturally." 

Anaphylaxis. — Foreign  proteins,  not  in  themselves  poisonous  or 
unduly  irritating,  injected  into  the  blood,  may  so  sensitize  the  pa- 


FiG.  56. — Intraspinal  injection  is  more  difficult;  but  much  more  efficient  when  it  is 
necessary  to  bring  protecting  substances  quickly  into  contact  with  infected  nervous  tissue, 
such  as  the  brain  and  spinal  cord. 

tient  to  that  particular  protein  that  when  a  second  dose  is  admin- 
istered the  individual  is  apparently  poisoned  or  injured  by  it. 
This  sometimes  occurs  when  a  second  dose  of  antitoxin  is  given. 
The  substance  that  should  have  protected  the  patient  has  apparently 
left  him  without  any  protection  {ana,  without,  therefore  ana-phy- 
laxis).  Sensitiveness  to  certain  foods  is  sometimes  explained  in 
the  same  way.  It  is  thought  by  some  that  a  baby  may  be  given  too 
much  of  a  new  food  the  first  time  and  form  too  much  of  a  given 
enzyme  or  other  reacting  substance;  lie  is  then  sensitive  to  that 
substance,  and  reacts  very  strongly  when  next  it  enters  the  body. 
Such  food-sensitives  are  not  uncommon  for  strawberries,  milk,  and 


TREATMENT  AND  PREVENTION  OF  DISEASE 
Substances  Used  in  Treating  or  Preventing  Disease 


211 


Protecting  Substance 


Disease 


Remarks 


Whole  blood . 


Whole  serum . 


Purified  serum  or  an- 
titoxin 

Living  organisms  (or 
vaccines ) 


Killed  organisms 
(also  called  vac- 
cines) 


Scarlet  fever 

Anaemia 

Loss  of  blood,  e.g.,  by 

wounds 
Pneumonia 

Meningitis 

Tetanus 


Gas  gangrene . 


Diphtheria 
Smallpox 

Rabies 

Typhoid.  ... 

Paratyphoid 

Dysentery 

Cholera 
Tuberculosis 

Boils  and  skin  erup- 
tions 

Plague 

Whooping  cough .... 


Obtained   from    convalescents; 

their  serum  only  also  used 
[Not  to  add  antibodies,  but  to 
I     supply  oxygen-holding  power, 
[     etc. 
Not    helpful    in    all    tj^pes    of 

pneumonia 
Preferably    injected    intraspin- 

ally 
Preferably    injected    intraspin- 

ally  in  advanced  cases 
Now  obtained  from  the  same 
horses  that  produce  tetanus 
antiserum.  (The  horses  are 
injected  with  two  toxins :  tet- 
anus and  gas  bac;  Uus . )  This 
double  serum  was  tried  at 
the  front  with  promising 
results 


Originally  obtained  from  cow- 
pox;  now  smallpox  organisms 
which  have  been  grown  in 
healthy  caK  are  used 

Now  obtained  from  spinal  cord 
of  rabid  rabbits 

Immunity  lasts  2-5  years 

[Intestinal  disorders;  typhoid 
J  was  used  with  these  to  make 
1  the  "triple  vaccine"  used  on 
[     all  our  army  in  the  recent  war 

Killed  tuberculosis  bacteria  are 
called  tuberculin;  not  cura- 
tive; helpful  in  other  ways 
(healing,  etc.)? 

Staphylococcus  and  the  acne 
bacillus  are  the  common  or- 
ganisms used 

Useful  in  epidemics  only,  as 
immunity  lasts  but  a  short 
time 

Either  the  pertussis  (whooping 
cough  ?)  or  the  influenza  or- 
ganism gives  fairly  good  results 


212 


HOME  AND  COMMUNITY  HYGIENE 


Protecting  Substance 

Disease 

Remarks 

Killed   organisms 
(also   called   vac- 
cines) 

Filtrates     of    killed 

Common  colds 

Diphtheria 

Various  pure  and  mixed  vac- 
cines are  used,  benefits  most 
uncertain 

Recently  used  for  exciting  anti- 

bacteria or  toxins 

Replacing    bacteria 
by  other  kinds 

Typhoid ] 

Intestinal       disturb- 
ances, includingdys-  [• 
entery  and  chronic 
indigestion                J 
Diphtheria 

toxin  in  children;  a  Httle  anti- 
toxin is  mixed  with  the  toxin 
to  lessen  the  shock  and  irri- 
tation 

Sour     milk     containing     acid- 
forming     bacteria     used     as 
foods.    See  page  89 

Carriers  are  sometimes  cured  by 

having  less  harmful  bacteria  (e. 
g.,  Staphylococcus)  implanted  on 
the  throat 

eggs.  Sometimes  the  sensitiveness  varies  with  the  treatment  the 
food  has  undergone  (e.g.,  cooking).  People  who  are  subject  to  hay 
fever,  rose  cold,  etc.,  are  thought  to  have  been  previously  sensitized 
by  pollen  from  such  plants  or  similar  substances.  The  repeated 
use  of  tuberculosis  proteins  in  tuberculin  is  by  Vaughn  and  others 
classed  as  dangerous  for  much  the  same  reasons.  Some  of  our  best 
sanatoriums  still  continue  this  treatment,  however. 

PROBLEMS 

1.  When  measles  were  first  introduced  into  the  Faroe  Islands,  over 
6000  of  the  7782  inhabitants  contracted  the  disease;  show  why  that  pro- 
portion' could  not  be  reached  in  any  of  our  communities  to-day  for  measles. 
What  part  does  "a  wall  of  the  immune"  play  in  controlling  communicable 
diseases? 

2.  Consult  one  of  the  bacteriologies  given  in  the  reference  list  and  make 
a  list  of  the  diseases  in  which  prevention  by  vaccination,  etc.,  is  possible. 
Check  those  which  have  come  under  your  own  observation.  What  is  the 
relative  prevalence  of  such  communicable  diseases? 

3.  Write  a  popular  article  in  favor  of  antitoxin,  making  it  so  clear  and 
convincing  that  it  would  appeal  to  an  eighth-grade  child. 

4.  The  statement  has  been  made  that  the  cure  for  quarantine  is  sani- 
tation. What  sanitary  measures  would  make  an  epidemic  of  typhus  fever 
impossible  in  your  city?  One  of  cholera?  Of  smallpox?  Of  yellow  fever? 
Of  plague? 

5.  In  the  diagram  (Fig.  52)  what  period  represents  the  so-called  crisis 
of  a  disease,  the  point  that  means  recovery  or  death?  Why  is  the  recovery 
often  very  rapid  after  this  crisis  is  passed  ? 

See  Reference  List  at  end  of  Appendix. 


CHAPTER  XII 
TESTS  FOR  DISEASE  1 

The  presence  of  disease  organisms  in  our  bodies  may  be  demon- 
strated in  two  main  ways:  (1)  by  examination  of  secretions  and 
diseased  tissue  for  the  suspected  bacteria;  and  (3)  by  demonstrat- 
ing that  tlie  body  has  formed  certain  of  the  antibodies  we  have 
already  discussed  {e.g.,  agglutinins).  The  presence  of  such  anti- 
bodies is  considered  proof  that  the  individual  has  had  or  now  has 
the  related  disease.  These  tests  for  disease  are  most  important  aids, 
not  only  to  the  individual  but  to  the  whole  community.  They 
often  make  possible  an  earlier  diagnosis  of  a  given  disease  and  en- 
able the  patient  to  obtain  more  helpful  treatment;  they  also  pro- 
tect the  community  by  leading  to  an  earlier  establishment  of  isola- 
tion or  quarantine  when  that  is  necessary. 

Carriers. — In  certain  diseases,  e.g.,  typhoid  and  diphtheria,  the 
organisms  may  persist  in  the  body  even  after  the  individual  has 
apparently  recovered,  the  individual  having  acquired  a  tolerance  to 
the  organisms  thus  retained.  These  same  kinds  of  tests  enable  us 
to  determine  whether  or  not  the  bacteria  are  present  in  these  ap- 
parently well  people;  and  the  community  can  to  some  degree  pro- 
tect itself  against  these  carriers  by  dema,nding  their  isolation,  pro- 
viding curative  treatment,  or  refusing  to  allow  them  to  follow  occu- 
pations certain  to  spread  such  organisms  {e.g.,  food  handling  by 
typhoid  carriers). 

Microscopic  Tests. — Direct  examination  of  secretions,  etc.,  is 
the  method  often  employed  in  diphtheria,  tuberculosis,  gonorrhoea, 
typhoid  and  cholera.^    In  diphtheria  a  little  material  from  the  in- 

^  Chapter  XI  should  be  read  before  this  chapter.  These  tests  are 
mainly  biological  tests;  other  tests,  such  as  X-ray,  though  important,  are 
not  included  here. 

*  These  are  not  the  only  methods  used  for  these  diseases.  They  are, 
however,  in  general  use,  and  typical  of  methods  used  in  other  diseases  too 
complicated  to  describe  in  this  type  of  book ;  these  descriptions  are  designed 
to  give  but  a  general  idea  of  these  tests.  Training  is,  of  course,  necessary 
to  make  and  interpret  such  tests;  this  includes  a  special  technic  desirable 
both  from  the  standpoint  of  the  individual  and  the  community,  protecting 
the  patient  by  the  use  of  sterile  instruments  for  the  collection  of  material, 
and  the  community  by  properly  handling  and  disposing  of  such  materials. 

213 


214  HOME  AND  COMMUNITY  HYGIENE 

fected  throat  is  rubbed  upon  a  glass  slide.  When  this  is  stained 
(G)  diphtheria  organisms  may  be  identified  in  the  microscope  by 
their  characteristic  ap|)earance  (rods  slightly  swollen  at  one  end 
and  presenting  with  appropriate  stains  an  unequally  stained  or 
spotted  appearance,  Fig.  57).  Streptococcus  infections  are  also 
e^isily  identified  microscopically  (Fig.  58)  (septic  sore  throat,  mas- 
toid abscesses,  etc.).  Tuberculosis  is  diagnosed  in  much  the  same 
way.  Sputum  (G)  from  a  tuberculosis  suspect  is  placed  upon  a 
glass  slide  and  stained;  once  stained,  tuberculosis  bacteria  retain 
their  stain  with  great  tenacity,  even  when  bleached  for  a  short 
time  in  alcohol  or  acid.    If,  after  bleaching,  deeply-stained,  slightly 

Fig.  57. 


'.,5%- 


,;«?*.■ '- 


Fig.  58. 

1 

f'A 


Fig.  57.  —  Diphtheria  organisms  magnified  more  than  1000  times,  showing  distinctly 
their  unequal  staining  character. 

Fig.  58. — Streptococcus,  a  long-chained  form,  important  as  causal  organism  in  many- 
different  disease  conditions,  such  as  mastoid  abscesses,  scarlet  fever  sore  throats,  and  blood 
poisoning. 

granular  rods  are  found,  the  case  is  diagnosed  as  tuberculosis 
(Fig.  94). 

A  common  way  of  diagnosing  gonorrhoea  is  by  examining  micro- 
scopically mucus  from  the  inflamed  area  (eye,  genital  region).  If 
gonorrhoeal  in  character,  the  slide  when  stained  in  a  special  way 
will  show  peculiar  pairs  of  rounded  organisms  and  numerous  white 
corpuscles,  many  of  which  are  sure  to  contain  numbers  of  these  same 
rounded  organisms. 

In  meningitis  material  withdrawn  from  the  spinal  canal  (Fig. 
59)  is  examined  both  bacteriologicaliy  and  chemically.  This  spinal 
fluid  is  examined  bacteriologicaliy^  by  making  a  direct  examination 


TESTS  FOR  DISEASE 


215 


to  determine  the  causal  organisms.     Parallel  chemical  tests  relat- 
ing to  the  sugar  and  albumin  content  of  this  fluid  are  often  made. 

Diagnosis  by  Isolating  Organisms. — Meningitis,  typhoid,  and 
cholera  are  diagnosed  in  a  different  way.  The  nasal  secretions  in 
meningitis  carriers  and  the  fasces  in  typhoid  and  cholera  patients  as 
well  as  carriers  contain  the  disease-producing  organisms.     A  little 


Fig.  59. — -One  method  of  collecting  spinal  fluid  for  bacteriological  and  chemical  examina- 
tion; a  similar  but  horizontal  position  is  usually  considered  preferable. 

of  the  nasal  excretion  or  a  little  of  the  faces  is  spread  out  on  a 
plate  of  (solid)  material  favorable  to  the  growth  of  the  suspected 
organisms.  In  the  resulting  growth  on  the  plate  it  is  quite  easy  for 
an  experienced  person  to  identify  the  colonies  of  meningitis, 
typhoid,  etc. 

Agglutination  of  Isolated  Organisms.— These  organisms  can 
be  positively  identified,  however.  In  meningitis,  for  example,  a 
little  of  the  selected  colony  is  mixed  with  serum  obtained  from  a 
person  known  to  have  meningitis.    If  the  growth  is  meningitis,  the 


216  HOME  AND  COMMUNITY  HYGIENE 

organisms  are  agglutinated  or  clumped  by  the  serum  as  described  in 
the  preceding  chapter  (p.  196). 

Diagnosis  by  Antibodies  in  Blood. — The  second  way  of  prov- 
ing that  a  person  has  a  given  disease  is  by  demonstrating  that  he 
has  formed  in  his  body  certain  of  the  antibodies  we  have  already  dis- 
cussed (see  p.  196).  In  diagnosing  typhoid  a  little  blood  is  taken, 
and  to  this  blood  (or  preferably  the  serum)  are  added  some  known 
typhoid  organisms.  If  the  organisms  are  agglutinated  by  the  pa- 
tient's serum,  we  know  he  has  the  same  antibody  (agglutinin)  that 


^  -   \ 

/ 

V -^ 

'"1 

^            * 

/ 

^'.  ''  1 

(           ■*   . 

^' 

7 

/^ 

J- 

_     i 
i 

'  ■^'■>. 

'''    ! 

(."^ 

>. 

1-  ■   ■  / 

.       1 

Fig.  60. — A  drop  of  broth  containing  free-swimming  typhoid  organisms,  magnified  about 

1000  times. 

typhoid  calls  out,  and  conclude  he  has  typhoid  fever  (Widal  test, 
Figs.  60  and  61). 

Tubercular  people  may  be  shown  to  have  tuberculosis  by  their 
reaction  when  killed  tuberculosis  organisms  (tuberculin)  are  in- 
jected into  them.  Swelling  and  reddening  at  the  place  of  injec- 
tion and  fever  are  the  main  reactions  looked  for;  if  these  occur 
within  a  specified  time,  it  indicates  that  the  individual  has  tuber- 
culosis. This  test — the  tuberculin  test — is  very  well  known;  but 
many  people  feel  it  is  not  a  wholly  reliable  test  for  active  tuber- 
culosis, partly  because  people  who  have  had  tuberculosis  at  some 
time  and  recovered  may  retain  the  reacting  substances  for  a  long 
time,  and  therefore  react  positively  to  the  test.  It  is  much  more 
reliable  for  cattle  than  for  man. 


TESTS  FOR  DISEASE 


217 


One  of  the  newer  tests  is  the  Schick  test  to  determine  whether 
a  person  is  liable  to  diphtheria ;  in  this  a  small  amount  of  diphtheria 
toxin  is  injected  into  the  arm.  If  the  individual  has,  naturally  or 
because  of  an  earlier  attack  of  the  disease,  the  necessary  neutralizing 
substance  in  his  blood,  the  toxin  will  be  absorbed  with  a  minimum 
amount  of  swelling,  redness,  etc. ;  if  the  individual  is  susceptible  to 
diphtheria,  the  toxin  thus  injected  will  not  be  neutralized  and  will 
therefore  be  irritating,  and  cause  a  certain  type  of  persistent  red- 
dened swelling;  such  people  should  be  protected  from  diphtheria 


Fig.  61. — Typhoid  organisms,  clumped  or  agglutinated  by  the  addition  of  the  serum  of  a 
person  who  has  typhoid. 


(especially  if  an  epidemic  is  threatened)  by  a  dose  of  antitoxin,  or 
by  the  newer  modified  toxin  treatment  (p.  207).  This  test  is  very 
valuable — showing  which  of  the  exposed  individuals  need  protection, 
and  making  it  unnecessary  to  use  antitoxin  treatment  on  those  who 
do  not  need  it — a  saving  of  thousands  of  dollars  yearly  in  children's 
institutions,  including  schools. 

Difficulties  in  Diagnosis. — Occasionally  such  tests  fail.  This 
is  not  because  they  indicate  that  the  disease  is  present  when  it  is 
not,  but  because  they  fail  to  indicate  the  presence  of  the  disease 
organisms,  giving  negative  results  instead  of  positive  ones.  Most 
of  these  ar^  easily  explainable.    The  small  sample  used  from  the 


218 


HOME  AND  COMMUNITY  HYGIENE 


nose,  throat,  or  faeces  may  not  chance  to  contain  any  of  the  organ- 
isms. In  the  other  tests,  depending  upon  the  formation  of  agglu- 
tinins, etc.,  a  negative  result  may  be  secured  at  the  beginning  of 
the  attack,  because  the  patient  has  not  yet  begun  to  react  to  the 
bacteria.  In  serious  or  fatal  illnesses  where  the  patient  is  not  suc- 
cessfully combating  the  disease,  it  is  partly  because  he  is  probably 
not  producing  sufficient  antisubstances  to  protect  himself  or  to  show- 
up  in  a  test.  In  such  cases  the  clinical  or  bedside  symptoms  are 
usually  quite  definite  and  positive,  however. 

Common  Tests  Depending  on  the  Presence  of  Antibodies  in  the 
Patient's  Blood 


Antibodies  present 


Antitoxins . 


Agglutinins  (and  pre- 
cipitins) 


Opsonins . 
Lysins . . . 


Diseases 


Diphtheria . 


Typhoid 
Paratyphoid 
Dysentery 
Pneumonia . . 


Transfusion  of  blood 


Tuberculosis . 


Syphihs 
Gonorrhoea 
Whooping  cough 


Transfusion  of  blood 


Remarks 


Used  to  prove  immunity  to 
diphtheria,  not  presence  of 
disease 


Used  to  determine  type  of 
pneumonia  and  to  indicate 
whether  prepared  serums 
can  be  used  in  treatment 

IncompatibiUty  indicated  by 
the  rate  at  which  foreign 
cells  are  precipitated  by 
patient's  serum 

Used  mainly  to  indicate  the 
condition  of  the  patient;  not 
very  satisfactory,  appar- 
ently 

These  are  complicated  tests 
in  which  several  other  sub- 
stances may  be  used.  In 
sjTjhilis,  for  example,  if  the 
patient  has  syphilis,  his 
serum  affects  the  substances 
used  in  such  a  way  that  the 
red  blood  cells  also  added  to 
the  mixture  are  not  dis- 
solved (Wasserman  test) 

Danger  indicated  if  the  pa- 
tient's serum  rapidly  dis- 
solves the  red  cells  in  the 
blood  to  be  injected 


TESTS  FOR  DISEASE  219 

PROBLEMS 

1.  The  tests  described  in  this  chapter  have  been  described  in  the  simplest 
form  possible;  they  are  really  much  more  detailed  and  complicated.  What 
arguments  can  you  advance  for  having  a  special  city  or  county  laboratory 
for  making  such  tests?  (Include  cost  of  equipment,  necessary  training  in 
chemistry  and  bacteriology,  and  the  time  demanded.) 

2.  Which  of  these  tests  do  the  physicians  in  your  town  make  in  their 
daily  practice?    Are  more  needed  for  the  full  protection  of  the  community? 

3.  Visit  the  nearest  health  department  laboratory  and  find  what  micro- 
scopic and  biological  tests  are  made  there.  What  tests  are  made  for  disease 
in  animals  other  than  man? 

8ce  Reference  List  at  end  of  Appendix, 


CHAPTER  XIII 

THE  HOME 

^  Most  of  us  are  individually  responsible  for  the  care  and  hy- 
gienic conditions  of  a  small  number  of  rooms  or,  at  least,  a  single 
room,  Tor  each  of  us  the  problems  are  much  the  same,  as  even  the 
occupant  of  a  single  room  must  share  with  others  the  bath  and 
toilet  facilities,  and  also  the  commodities  stored  and  prepared  in 
the  cellar,  kitchen,  and  dining  room  of  the  same  building,-  or  in  one 
differing  little  in  sanitary  conditions.  Whether  one  builds  his  own 
house  or  leases  an  apartment  or  only  a  single  room,  the  hygienic 
interests  and  responsibilities  ^  are  still  the  same,  for  in  each  case 
there  is  an  element  of  choice. 

The  main  considerations  {e.g.,  water,  ventilation)  are  all  treated 
separately  in  other  parts  of  this  book.  The  purpose  of  this  chapter 
is  to  make  the  problems  more  concrete  for  the  sake  of  the  indi- 
vidual housekeeper.  Even  with  the  services  of  a  capable  architect 
conversant  with  all  the  sanitary  details,  one  may  find  faulty  con- 
struction which  will  always  affect  the  occupants,  such  as  too  great 
consideration  for  the  outside  appearance  of  the  house  which  may  so 
space  the  windows  that  a  room  has  but  a  single  window  and  that  on 
the  sunless  side  of  the  house.  Of  what  avail  are  city  ordinances 
requiring  windows  in  bathrooms,  if  soiled  or  leaking  toilets  are 
tolerated  ?  What  benefit  does  a  taxpayer  derive  from  an  expensive 
system  of  garbage  removal,  if  accumulations  of  table  refuse  draw 
the  disease-carrying  flies  and  mice  to  his  own  kitchen  ? 

Housing  Regulations. — Housing  laws  are  intended  to  provide 
proper  standards  for  the  erection,  maintenance,  and  alteration  of 
dwellings,  that  is,  "  buildings  occupied  in  whole  or  part  as  the  home 
residence  or  sleeping  place  of  one  or  more  human  beings  either 
permanently  or  transiently."  It  is  remarkable  that  this  type  of 
social  legislation  which  was  drawn  first  to  safeguard  the  tenement 

^  Those  responsible  for  building  or  planning  houses,  or  even  one-room 
schools,  small  churches,  etc.,  should  consult  more  advanced  books  than 
this,  including  not  only  those  mentioned  in  this  book,  but  the  more  techni- 
cal authorities  to  which  they  may  in  turn  refer. 

220 


THE  HOME  221 

dwellings  in  congested  quarters  of  large  cities  is  now  widening  its 
scope  to  propose,  at  least,  certain  standards  for  every  dwelling 
within  a  State,  whether  in  the  city  or  rural  district,  whether  a  one- 
family  house  occupied  solely  by  the  owner's  family,  or  a  multiple 
dwelling  occupied  by  many  families.  The  principal  provisions  of 
such  laws  as  given  by  Yeiller  in  his  "  Model  Housing  Law  "  con- 
cern guarantees  of  adequate  light  and  ventilation,  proper  sanitary 
provisions,  fire  protection,  and  suitable  conditions  of  occupancy. 
Adequate  light  and  ventilation  is  made  certain  by  (a)  limiting  the 
proportion  of  a  given  city  lot  which  can  be  covered  by  the  dwelling 
(e.g.,  70  per  cent,  or  less  of  the  area  of  an  ordinary  interior  lot  and 
85  per  cent,  of  an  ordinary  corner  lot)  ;  (h)  requiring  that  the 
rear  of  every  lot  be  left  as  an  unoccupied  area  of  at  least  15  per 
cent,  on  a  corner  lot  and  25  per  cent,  on  an  interior  lot;  (c)  that 
side  yards,  if  used,  should  have  a  minimum  width  and  be  open  to 
the  sky;  (d)  that  every  room  is  to  have  at  least  one  window  open- 
ing on  the  street,  or  yard  or  court,  which  must  be  of  specified  size 
(small  courts  or  air  shafts  are  forbidden  by  rigorous  requirements)  ; 
and  the  area  of  these  outside  windows  must  be  at  least  one-seventh 
the  floor  area  of  the  room  (this  provision  makes  illegal  inside  rooms, 
dark  rooms,  and  alcove  rooms)  ;  (e)  every  room  except  the  toilet 
must  have  at  least  90  square  feet  floor  area,  and  in  multiple  dwell- 
ings there  must  be  in  each  apartment  one  room  of  150  square  feet, 
and  no  room  may  be  less  than  9  feet  high. 

The  sanitary  provisions  require  running  water  and  indoor  flush 
toilets  in  every  dwelling  and  family  unit  of  every  dwelling;  the 
bathroom  as  such  is  not  required  by  the  housing  law.  Detailed 
safeguards  regarding  fire  prevention  are  also  included ;  these  cover 
exits,  fire  escapes,  and  the  methods  and  materials  of  house 
construction. 

The  legal  standards  regarding  maintenance  include  the  care 
and  cleaning  of  halls,  cellars,  and  courts  in  multiple  dwellings ;  the 
disposal  of  ashes  and  garbage ;  prohibition  against  keeping  animals 
on  the  premises,  and  the  storage  of  combustible  material;  also 
standards  as  to  overcrowding,  and  relating  to  moral  conditions. 

Location. — ISTo  one  would  from  choice  select  marshy  ground  as 
a  site  for  a  house.  Even  the  small  surface  bodies  of  water  in 
places  but  slightly  marshy  are  dangerous  as  well  as  unsightly,  as 
they  afford  breeding  places  for  malarial  mosquitoes.     It  is,  how- 


222  HOME  AND  COMMUNITY  HYGIENE 

ever,  no  unusual  thing  to  find  houses  on  the  edges  of  towns,  high- 
ways, and  railways  embarkments  more  or  less  surrounded  by  visible 
water  a  considerable  part  of  the  year.  Made  ground  is  usually 
filled-in  marsh  land  and  is  often  water-soaked;  it  may  also  yield 
objectionable  odors  due  to  the  refuse  used  for  filling  in. 
^  Water-soaked  soil  is  not  favorable  for  gardens  either  for  flowers 
or  vegetables.  In  such  soils  the  water  replaces  the  air  ordinarily 
present  in  soil,  and  the  roots  suffer  for  lack  of  oxygen.  (Every- 
one can  doubtless  recall  seeing  wheat  or  other  crops  which  had  sickly 
yellow-green  color  during  a  long-continued  wet  spell  in  spring  or 
early  summer.) 

Damp  soil  (where  the  level  of  the  ground  water  is  very  near 
the  surface)  can  take  care  of  very  little  extra  water  {e.g.,  rains, 
house  water).  Such  soil  is  liable  to  become  temporarily,  at  least, 
wet  and  sour  or  foul-smelling.  During  this  present  year  one  of 
King  George's  palaces  in  London  was  refused  as  a  hospital,  because 
it  was  found  impossible  to  avoid  unpleasant  gases  emanating  from 
the  soil  below,  which,  during  the  centuries  before  modern  plumbing 
was  installed,  had  been  soaked  by  house  and  stable  waste.  Queen 
Victoria,  it  is  said,  claimed  the  conditions  affected  her  health,  and 
would  not  stay  over  night  in  the  palace  and  never  more  than  a  few 
hours  at  a  time. 

Cellars. — Cellars  in  wet  ground  usually  contain  water,  unless 
considerable  money  is  spent  in  waterproofing  the  outer  or  soil  sides 
of  the  walls  and  floor.  Loosely  filled  layers  of  stone  may  also  be 
placed  outside  and  close  to  the  foundation,  with  a  drain  near  the 
bottom  of  the  foundation  wall  to  carry  off  the  water  that  collects 
there  (Figs.  62  to  65). 

As  the  air  in  the  house  becomes  heated  and  rises  through  the 
house,  it  is  replaced  by  outside  air.  Part  of  this  comes  through  the 
windows  and  doors  on  the  various  floors ;  sometimes  a  special  fresh 
air  intake  is  provided;  much  of  it  comes  from  the  cellar  and  the 
adjacent  soil.  Too  great  care  in  closing  all  the  cracks  of  the  doors 
and  windows  may  increase  the  amount  of  cellar  and  soil  air  re- 
placing the  air  which  is  constantly  passing  out  of  the  chimney  and 
upper  part  of  the  house.  In  fact,  the  greatest  precautions  (asphalt 
insulation,  etc.)  are  necessary  to  prevent  considerable  replacement 
by  soil  air.    Since  these  involve  considerable  expense  and  delay  the 


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223 


beginning  of  building  operations,  they  are  rarely  taken,  unless  there 
are  indications  that  water  will  actually  flood  the  cellar. 

Though  the  ground  water  level  (G)  meets  the  requirements 
(eight  to  ten  feet  below  the  surface),  the  cellar  -floor  may  be  near 
or  even  below  that  level  and  the  cellar  may  be  surprisingly  damp, 
unless  the  floor  has  an  asphalt  layer  below  the  cement  (Fig.  64)  or  is 
underdrained  by  loose  stonework  below  the  cement  floor. 

The  cellar,  especially  in  country  districts,  is  often  but  a  dark, 
damp  hole,  so  damp  that  visible  moisture  is  usually  present  on  its 


r\oiL6n-DacKed  wall 


Fig.  62. — A  rough-backed  wall,  not  advisable  for  damp  soils,  as  it  has  projecting 
surfaces  in  which  water  may  collect.  What  will  be  the  effect  on  such  walls  if  the  collected 
water  freezes? 

walls,  and  so  poorly  windowed  and  ventilated  that  it  is  musty- 
smelling;  it  is  quite  common  for  cellars  to  be  so  dark  that  one  has 
to  find  things  "  by  the  feel "  instead  of  sight,  and  if  work  is  done 
in  the  cellars  (skimming  milk,  cutting  meat),  the  materials  must 
be  carried  close  to  the  window.  The  dirt  floors,  the  moldy  boards 
for  walking,  and  the  musty  shelves  and  benches  are  doubtless 
familiar  to  many  readers.  Many  a  person  has  grown  to  maturity 
without  ever  seeing  a  cellar  that  had  a  cement  floor  or  two  windows 
placed  to  insure  cross  ventilation. 

It  takes  an  undue  amount  of  a  housekeeper's  time  to  be  con- 
stantly dragging  boards,  benches,  and  shelves  out  into  the  sun  to 
keep  things  fresh  and  clean.  The  cellar  ought  to  be  as  easy  to  care 
for  as  any  other  room  in  the  house.    Usually  it  is  so  unattractive  a 


224 


HOME  AND  COMMUNITY  HYGIENE 


task  that  the  animal  spring  cleaning  and  whitewashing  have  "  a 
hated  deed  done  "  as  their  only  incentive. 

Cellars  that  grow  musty  easily  should  be  cleaned,  aired,  and 
whitewashed  often — more  than  once  a  year.  Whitewashing  need 
not  be  made  a  distasteful  or  difficult  task,  now  that  lime  can  be 
secured  in  tin  cans.  An  old  tub  or  barrel  can  be  kept  for  mixing 
purposes,  and  with  a  tin  spray  pump  costing  but  $.60  to  $.90,  the 
xime  can  be  squirted  over  the  walls,  especially  in  the  darker  corners. 
Lime  is  probably  the  only  legitimate  deodorizer,  as  it  also  covers 
the  old  surface  with  a  fairly  efficient  disinfectant. 


VQ-n'bacfied    wa  II 


D 


raiti  - 


Fig.  63. — This  smooth-backed  wall  does  not  have  the  two  disadvantages  implied  in  Fig.  62; 
the  drain  at  the  bottom  is  an  added  protection  against  dampness. 


Exposure  and  Light. — One  is  often  at  a  loss  to  account  for  the 
locations  of  old  houses.  Views  and  a  convenient  distance  from  the 
road  were  usually  sacrificed  to  two  things :  nearness  to  the  spring  or 
well,  and  shelter  from  the  winter  blasts.  The  position  of  the  barns 
and  other  out-houses  was  a  matter  of  less  concern;  this  accounts 
for  their  common  location  higher  on  the  valley  sides  than  the 
springs  or  well.  That  this  aroused  little  concern  is  not  surprising, 
for  the  first  well-borne  epidemic  due  to  fecal  contamination  was 
not  worked  out  until  1854.  To-day  the  relative  location  of  the  cess- 
pool and  well  are  equally  important. 

^^  Facing  the  south  "  is  such  a  familiar  term  that  it  needs  no 


THE  HOME 


225 


explanation.  Too  often  the  coveted  exposure  goes  to  the  unused 
parlors  and  the  living  and  working  rooms  are  sacrificed.  If  the 
house  is  placed  so  that  one  side  faces  either  the  southeast  or  the 
southwest,  then  every  side  of  the  house  has  direct  sunlight  part  of 
the  day.  ISTote  (Fig.  66)  the  difference  this  would  make  to  the 
kitchen,  which  so  often  is  a  rear  addition  to  the  main  part  of  the 
house. 

The  stimulating  effect  of  sunlight  is  realized  by  but  a  few;  its 
disinfecting  value  is  still  less  appreciated.  It  is  not  unusual  to  find 
the  shades  down  for  days  at  a  time — not  to  shut  out  the  glare,  but 


'tV^ 


jartK 


T~~r 


TTT 


M 


-  ce ry\e 


n  t  (.co«.ted/  wttn  tar) 


— U — L  Xe"mc.-nt 

^~n^(imi\l\illHlll(llWllhlllllO^  «-nd 


f^fo.-r   Axid     Oiiokoiit 


CeiY\e-n  t 


Fig.  64. — It  is  sometimes  desirable  to  collect  the  drainage  water  some  distance  from 
the  house,  as  in  this  diagram.  Note  the  cement-tar  layer  to  prevent  the  upward  transfer 
of  moisture  through  the  walls.    The  cellar  floor  is  similarly  treated. 

to  keep  the  furniture  and  carpets  from  fading.  Even  to-day  there 
are  housekeepers  within  an  hour's  distance  of  Philadelphia  or  New 
York  affected  with  such  an  acute  form  of  "  carpetitis  "  that  news- 
papers are  spread  upon  the  carpet  when  the  shades  are  raised.  The 
cheapest  and  quickest  of  our  natural  disinfectants,  sunlight,  is  lost 
by  concern  for  carpet  roses. 

Artificial  Lighting. — ^The  lighting  problems  are  chiefly  con- 
cerned in  remedying  two  extremes:  too  little  light  and  too  much 
light.     It  is  by  no  means  unusual  to  find  halls  and  bathrooms  so 
dimly  lighted  that  one  can  barely  see  the  light  itself.    Some  standard 
15 


226 


HOME  AND  COMMUNITY  HYGIENE 


(such  as  reading  newspaper  print  at  a  given  distance)  should  be 
demanded  of  all  people  who  rent  out  one  or  more  rooms  or  apart- 
ments. Gas  lights  should  not  be  turned  so  low  that  ordinary  drafts 
would  blow  them  out.  Kerosene  lamps,  if  turned  too  low,  give  out 
a  disagreeable  smell  due  to  the  fact  that  the  small  flame  does  not 
cause  complete  combustion.  The  "  mellow "  light  claimed  as  an 
advantage  of  the  kerosene  light  can  be  secured  very  easily  from  gas 
or  electricity  by  proper  shades.     (See  paragraph  following.)     The 


Fig.  65. — Air  spaces  are  also  helpfxil  in  counteracting  the  effects  of  damp  soil  against  the 

wall. 


electric  light  has  two  great  advantages  besides  convenience;  (1)  it 
is  easily  and  safely  led  off  or  adjusted  to  more  convenient  positions, 
and  (2)  it  does  not  complicate  the  heating  and  ventilation  prob- 
lems as  gas  and  oil  do.  Both  gas  and  kerosene  add  heat  to  the  sur- 
rounding air;  both  reduce  the  amount  of  oxygen;  kerosene  may 
give  out  objectionable  odors  and  smoke,  and  there  is  a  risk  of 
CO  (G)  poisoning  in  illuminating  gas  (see  Chapter  "VI ).  Arti- 
ficial light  has  a  slight  inhibiting  effect  upon  bacteria,  another  argu- 
ment for  its  generous  use. 

Formerly  brilliancy  of  illumination  seemed  our  sole  aim.  No 
light  was  ever  put  "  under  a  bushel,"  but  even  electric  lights  were 
placed  in  the  most  exposed  parts  of  the  room,  with  a  reflector  back 
of  each.    Fortunately  indirect  lighting  is  now  fashionable  and  our 


THE  HOME 
N 


227 


Fio  66  —The  heavy  curve  shows  the  course  of  the  sun  on  the  shortest  day  in  winter, 
the  broken  Hne  on  the  longest  day  in  summer  Notice  how  little  hght  really  enters  the  east 
and  west  windows  in  winter  in  the  face-to-the-south  exposure  \u  ^iJ'-t^^n  P^tteMio^ 
south  position  notice  the  better  illumination  of  all  rooms,  including  the  kitchen  extension. 


228  HOME  AND  COMMUNITY  HYGIENE 

public  buildings,  halls,  etc.,  quite  generally  have  shades  between 
the  eye  and  the  source  of  light.  Translucent  bowl-like  coverings 
hang  just  below  the  ceiling  light  and  curved  semi-opaque  shades 
are  placed  in  front  of  the  wall  lights.  These  usually  serve  two 
purposes.  They  give  out  through  these  coverings  a  soft  mellowed 
light,  which  is  widely  diffused  through  the  room ;  much  of  the  light 
is  thrown  up  against  the  ceiling  or  back  against  the  wall  and  from 
there  reflected  back  into  the  room. 

Indirect  lighting  means  a  more  diffused  light  and  a  less  glaring 
light,  and  consequently  less  eye  strain.  In  private  homes  it  is  used 
mostly  in  halls,  reception  rooms,  or  for  the  general  lighting  of  a 
room.  Eooms  used  for  reading,  writing,  or  other  close  work  should 
have  attachments  placing  the  light  near  the  hand  or  working  level. 
A  translucent  globe  (open  at  the  bottom)  gives  through  the  globe 
a  diffused  light  throughout  the  room,  and  through  the  opening 
throws  most  of  the  light  downward  on  the  work  at  hand.  If  this 
is  too  strong,  thin  gauze  or  silk  can  be  dra^vn  across  the  opening  at 
the  bottom  of  the  globe,  giving  a  softer  light.  Some  advocate  a 
green  glass  globe,  half-spherical  in  shape,  which  is  turned  toward 
the  eye,  the  open  side  toward  the  wall,  and  the  light  is  reflected 
from  the  wall  to  the  work.  Most  people  express  a  feeling  of  im- 
patience with  indirect  light  of  this  last  type  for  close  work,  and 
though  it  is  quite  probable  that  habit  may  make  us  demand  irri- 
tating over-brilliancy,  it  seems  as  if  it  is  often  an  individual  mat- 
ter, and  each  should  control  his  individual  arrangement  for  close 
work.  For  general  illumination,  there  can  be  no  doubt  that  indirect 
lighting  should  be  adopted. 

Heating  and  Ventilation. — The  various  methods  of  heating 
may  be  divided  into  two  groups:  (1)  those  involving  a  special  heat- 
ing plant  in  the  cellar  or  basement  and  supplying  heat  by  pipes  or 
flues  to  the  various  rooms  of  the  house;  and  (2)  those  utilizing  the 
various  fuel  substances  {e.g.,  coal,  gas)  in  the  room  which  is  to 
be  heated. 

Hot-air  Furnaces. — Coal,  wood,  and,  less  often,  oil  are  burned 
in  specially  constructed  stoves  or  furnaces.  The  oldest  and  simplest 
of  these  special  furnaces  is  the  type  in  which  air  from  a  more  or  less 
confined  area  over  the  burning  fuel  is  collected  and  carried  in  large 
(tin)  pipes  to  various  rooms  on  higher  levels,  entering  the  rooms 
through  grated  inlets  set  into  the  floor  or  the  walls.     Such  air, 


THE  HOME  229 

even  with  careful  control  of  the  clampers,  often  carries  with  it  "  coal 
gas/'  including  disagreeable  odors  and  the  poisonous  CO  gas.  There 
is  often  a  burned  odor,  due  chiefly  to  dust  particles  which  find 
their  wa}'  froia  the  rooms  down  into  the  hot-air  flues.  Usually 
such  air  is  too  dry,  for  even  though  comparatively  fresh  outdoor  air 
makes  up  the  bulk  of  such  heated  air,  it  becomes  relatively  drier  as 
it  is  heated  (see  p.  12-i).  Often  it  is  so  dry  that  water  evaporates 
too  rapidly  from  the  body,  chilling  it;  and  to  prevent  this  chilled 
feeling  an  over-high  temperature  is  demanded.  A  "  water  box  "  is 
often  provided,  but  is  usually  too  small,  and  the  incoming  air  passes 
over  it  too  rapidly  to  take  up  the  necessary  amount  of  water. 
About  fifteen  gallons '  are  needed  daily  if  sufficient  moisture  is 
supplied  for  a  medium-sized  house  containing  17,000  cubic  feet. 
Usually,  too,  it  is  cold  outer  air  that  is  in  contact  with  the  water, 
not  the  warmed  air,  with  its  greater  holding  power  for  water,  and 
so  little  real  benefit  is  derived  from  the  water  box  (see  p.  144). 

Recent  Warmed-air  Systems. — Eecently  an  improved, 
"  warmed-air "  system  has  been  introduced.  The  air  that  passes 
through  the  furnace  in  the  system  just  described  is  not  used,  and 
all  the  products  of  combustion  jDass  with  it  out  the  chimney.  Fresh 
outdoor  air  is  taken  in  through  special  inlets  and  passed  in  closed 
pipes  through  the  upper  part  of  the  furnace  and,  as  it  becomes 
heated,  on  to  the  rooms.  This  avoids  the  objectionable  gases,  but 
may  leave  the  burned  odors  before  mentioned.  This  system  usually 
provides  water  contact  with  the  heated  air  to  increase  its  humidity. 

The  lack  of  moisture  in  room  air  can  be  partly  supplied  by 
dishes  of  water  exposed  in  the  room  or  by  boiling  water  for  a  short 
time.  "We  must  remember  that  steam  may  condense  on  the  cold 
windows  before  the  general  room  air  has  reached  a  favorable 
humidity.  Most  people  object  to  having  moisture  collect  on  the 
windows;  boiling  is  an  added  task,  and  dishes  of  water  are  apt  to 
collect  dust,  becoming  unattractive,  though  not  necessarily  harmful. 
It  is,  therefore,  much  wiser  to  see  that  the  incoming  air  has  in  it  a 
considerable  amount  of  water. 

Hot  Water  and  Steam  Systems. — In  the  other  special  heating 
plants  in  this  group  the  heat  of  the  furnace  is  used  to  heat  water. 
This  heated  water  either  circulates  through  the  house  as  warm 
water,  or  it  is  heated  enough  to  convert  it  to  steam,  and  the  steam 
passes  to  the  various  rooms.    As  the  warm  water  gives  out  its  heat, 


230  HOME  AND  COMMUNITY  HYGIENE 

it  becomes  chilled  and  relatively  heavier.  It  therefore  passes  to  the 
lower  pipes  and  finally  down  to  the  furnace  to  be  re-heated^  making 
a  constant  and  continuous  circulation.  Steam,  in  the  steam-heating 
system,  as  it  gives  its  heat  out  to  the  rooms,  is  condensed  to  water, 
and  this  water  similarly  makes  its  way  back  to  the  furnace. 

1  Hot-water  systems  give  out  heat  constantly,  even  though  but  a 
slow  fire  is  maintained ;  they  are  better  adapted  to  the  yearly  range 
in  temperature,  and  they  are  more  economical  of  time  and  fuel. 
Steam  has  the  disadvantage  of  not  providing  any  heat  except  when 
the  water  in  the  boiler  is  kept  at  or  above  the  boiling  point.  It,  of 
course,  responds  more  quickly  in  emergencies  (cold  snap,  heating 
after  an  unoccupied  period).  Both  these  systems  are  open  to  the 
same  objection  felt  in  the  hot-air  systems — excessive  dryness;  this 
condition  can  be  improved  only  by  exposing  added  water  (as  de- 
scribed) in  the  rooms  themselves.  Steam  heat  is  often  described 
as  more  drying  than  hot-water  heat.  There  is  really  no  difference, 
except  that  steam-heated  rooms  are  more  often  highly  overheated 
and,  therefore,  relatively  drier.  Hot-water  systems  do  not  give  out 
moisture. 

Room  Heaters. — In  the  other  type,  utilizing  the  fuels  in  the 
room  where  the  heat  is  desired,  we  have  the  methods  common  in 
small  houses,  one-room  schools,  etc.  Not  only  do  the  special  cellar 
heaters  imply  expensive  construction,  but  the  consumer  loses  much 
of  the  heat,  perhaps  half  the  fuel  value  of  his  coal.  In  most  homes, 
where  labor  is  rarely  valued  highly,  the  more  economical  plan  of 
utilizing  the  fuel  in  the  room  is  followed.  In  these  methods  the 
problems  are  mainly  ( 1 )  the  distribution  of  the  heat  evenly  through- 
out the  room,  and  (2)  the  avoidance  of  objectionable  products  of 
combustion  (e.g.,  CO,  odors).  The  choice  of  fuels  is  mainly  decided 
by  the  care  or  time  demanded,  and  the  cost.  Electricity,  unless 
water  power  can  be  utilized  for  its  manufacture,  is  an  expensive 
form  of  fuel,  as  it  represents  but  part  of  the  fuel  value  of  coal. 
It,  however,  presents  no  ventilation  or  labor  difficulties.  Gas,  too, 
represents  but  about  half  of  the  fuel  value  of  coal.  Gas  and  kero- 
sene mean  but  little  work,  but  they  make  heavy  demands  upon  the 
oxygen  of  the  room,  and  the  products,  including  those  of  incomplete 
combustion — smoke  in  kerosene,  and  the  poisonous  CO  gas  (G), 
especially  in  "water  gas"  (G) — all  pass  out  into  the  room.  Gas 
logs  in  apartment  houses  are  often  set  in  without  any  connection 


THE  HOME  231 

with  a  chimney  or  ventilating  flue.  Choice,  especially  in  the  coun- 
try, is  often  limited  to  the  cheaper  wood  and  coal,  coal  being  the 
favorite,  because  its  better  keeping  power  does  not  demand  constant 
replenishment.  Time  and  convenience,  however,  make  gas,  elec- 
tricity, and  kerosene  valuable  sources  of  heat.  As  emergency  aids, 
they  are  at  times  invaluable. 

In  general,  all  fuels  burned  in  the  room  are  open  to  the  same 
objections:  (1)  they  use  up  oxygen;  (2)  they  give  out  slight  odors 
accompanying  combustion;  (3)  they  may  give  out  harmful  products 
(smoke  in  kerosene  stoves,  CO  gas  from  coal  and  illuminating  gas, 
especially  if  an  incandescent  surface  is  present :  the  red-hot  sides  of 
a  coal  stove  or  the  char'coal-covered  burner  of  a  gas  stove)  ;  and  (4) 
they  are  almost  always  constructed  and  operated  without  any  pro- 
vision for  replacing  the  room  oxygen.  Though  the  oxygen  lack 
rarely  leads  directly  to  human  discomfort,  it  may  decrease  the  rate 
of  combustion.  This  is  more  marked  in  such  fuels  as  gas,  giving 
for  a  given  unit  of  gas  less  heat,  and,  unfortunately,  allowing  much 
gas  to  escape  into  the  room  unconsumed.  If  the  gas  is  "  water  gas," 
which  contains  a  large  amount  of  CO,  this  poisonous  gas  may  accu- 
mulate sufficiently  to  cause  stupor,  paralysis,  and  death. 

The  distribution  of  heat  in  the  room  is  a  difficult  problem.  Too 
often  the  floor  or  distant  corners  remain  cold,  while  the  stove  region 
is  uncomfortably  hot.  This  is  met  partly  by  placing  a  screen  or 
jacket  around  the  stove;  this  shields  those  near  by  and  still  allows 
a  general  distribution  of  the  heated  air  through  the  room. 

The  jacketed  stove  is  described  under  schools  (Chapter  XV, 
p.  260,  Fig.  80). 

Fireplaces. — ^Though  fireplaces  are  wasteful  as  heat  producers, 
they  combine  ventilating  benefits  with  some  heat  production ;  their 
use  is  to  be  encouraged,  especially  where  the  ventilation  is  insuffi- 
cient. Where  a  fire  is  burning  the  main  air  current  is  up  the 
chimney,  especially  if  adequate  air  enters  the  room  in  other  ways. 
In  a  fireless  fireplace,  colder,  heavier  air  may  be  entering  the  room 
through  the  fireplace.  (A  candle  will  indicate  the  relative  rate 
and  direction.)  Such  incoming  air  may  be  sooty  in  odor,  but  it  is, 
of  course,  unused  air. 

Franklin  Stoves. — The  Franklin  stoves  combine  the  possible 
advantage  of  the  fireplace  with  the  greater  heat  yield  of  most 
stoves;  having  dampers  to  control  the  escape  of  heated  air  up  the 


232  HOME  AND  COMMUNITY  HYGIENE 

chimney,  and  having  also  greater  radiation  surface  in  the  room 
itself.  In  all  these  methods,  the  humidity  tends  to  fall  below  the 
requirements  necessary,  and  this  need  should  be  met  as  recom- 
mended in  the  other  system,  or  more  rapid  evaporation  and  greater 
humidity  may  be  secured  by  keeping  pans  of  water  on  the  coal  stove, 
oij  heater,  under  or  on  the  gas  radiator. 

Ventilation. — ^The  heat  problems  are  summed  up  in  (1)  ade- 
quate heat  for  physical  comfort  with  a  generous  margin  for  fresh 
air  replenishment;  and  (2)  elimination  or  avoidance  of  objection- 
able products  (chiefly  CO). 

We  ventilate  freely  in  summer  time,  because  the  gains  are  real- 
ized immediately:  decreased  temperature,  increased  body  loss  of 
heat,  etc. ;  but  in  cold  weather  the  desire  or  necessity  for  economy 
dictates  very  different  action. 

We  must  reconcile  ourselves  to  the  loss  of  heat,  if  we  are  to  keep 
the  air  up  to  the  standards  of  comfort  and  cleanliness.  We  can- 
not get  rid  of  odors,  for  example,  without  losing  the  heat  in  that 
same  odor-bearing  air.  We  must  remember  that  we  are  paying  for 
good  heated  air,  and  not  heat  only.  Clean  unused  air  is  just  as 
important  as  clean  floors,  shining  windows,  and  dustless  furniture. 

Rules  for  Ventilation. — It  is  impossible  to  give  any  rules  for 
ventilation  that  will  suit  even  a  one-occupant  room.  The  natural 
ventilation  through  cracks,  porous  walls,  and  casually  opened  doors 
varies  greatly;  planned  ventilation  varies  even  more,  depending 
upon  the  size,  shape,  and  relative  position  of  the  openings  (Figs. 
33  to  35),  and  upon  the  difference  between  outdoor  and  indoor 
temperature.  The  main  current  in  a  fireplace,  as  already  shown,  is 
not  always  up  and  outdoors.  Adequate  ventilation  based  on  these 
differences,  the  size  of  the  room,  and  the  number  of  occupants,  can 
be  worked  out  mathematically,  but  that  method  cannot  be  briefly 
explained  in  usable  form.  Fortunately  there  are  two  simple  aids 
which  will  usually  accomplish  this  same  result:  (1)  a  thermometer, 
to  make  sure  the  room  does  not  become  overheated,  and  (2)  the 
human  nose.  Ko  room — ^night  or  day — should  smell  "  stuffy  "  to 
one  entering  from  outdoors.  In  the  daytime  frequent  short  trips 
outdoors  will  benefit  the  occupant  and  also  enable  her  to  judge 
of  the  quality  of  the  air. 

The  needs  of  most  home-makers  will  probably  be  met  by  the 
following  rule :  Ventilate  in  winter  much  as  you  do  in  summer.  In 


THE  HOME  233 

summer  no  diagrams  are  necessary  to  convince  people  that  two 
openings  are  better  than  one,  even  if  in  the  same  window;  that 
they  are  more  effective  if  on  different  or  opposite  walls  of  the  room ; 
and  that  a  cross  draft  changes  the  room  air  more  quickly. 

Night  Ventilation. — Night  ventilation,  if  it  means  cold  morn- 
ing dressing  rooms,  is  often  most  inadequate.  Where  space  allows, 
one  or  more  sleeping  porches  or  open-window  rooms  may  be  set 
aside  for  this  purpose,  the  individuals  using  the  warm  rooms  for 
dressing  rooms.  Most  families  do  not  have  an  extra  room  for  such 
purposes ;  in  fact,  every  room  is  usually  used  night  and  day.  Some- 
times, however,  inadequate  night  ventilation  has  no  excuse,  Ogden 
cites  a  family  of  five,  living  in  a  ten-room  house,  who  slept  in  one 
medium-sized  room  containing  but  one  small  window,  which  was 
nailed  shut.  Eecently  two  guests  visiting  a  country  relative  near 
New  York  City  found  themselves  consigned  to  a  bedroom  in  which 
all  the  windows  were  nailed  shut. 

If  the  night  temperature  falls  very  low,  outdoor  sleeping  will  be 
injurious,  unless  adequate  bedding  can  be  provided.  The  same 
benefit  can  be  derived  from  sleeping  indoors,  if  the  bed  is  placed  in 
such  a  position  that  the  head  of  the  sleeper  is  out  of  doors ;  or  the 
bed  may  be  left  wholly  inside  the  room,  and  some  form  of  sleeping 
hood  provided  which  will  not  necessitate  loss  of  room  heat.  That  is 
much  more  easily  done  than  most  people  imagine  (Fig.  36).  A 
string  or  pulley  attachment  for  closing  windows  a  little  before  the 
dressing  hour  will  reconcile  many  people  to  a  colder  bedroom  than 
they  will  otherwise  tolerate.     (See  also  Ventilation,  p.  139,) 

Kitchen, — ^Next  to  the  cellar,  the  most  important  room  in  the 
house,  from  the  point  of  view  of  health,  is  the  kitchen.  No  one 
will  contradict  the  statement  that  the  places  where  food  is  stored 
and  prepared  should  be  the  most  sanitary  places  in  the  whole  house. 
If  dinner  guests  at  many  an  elegant  home  could  have  one  pre- 
liminary glance  at  the  kitchen  or  watch  the  preparation  of  the 
food,  there  would  be  a  wild  rush  for  the  door. 

This  situation  is  partly  due  to  the  poor  quarters  provided  for  the 
kitchen  and  for  the  servants.  Have  you  never  wondered  why  it  is 
necessary  to  have  the  kitchens  little  stuck-on  additions  to  the 
houses?  Why  are  they  not  dignified  into  integral  parts  of  the 
house  ?  Instead,  we  find  the  rooms  where  mistress  or  maid  spends 
most  of  the  daylight  hours  cut  off  from  the  interests  of  the  street. 


234  HOME  AND  COMMUNITY  HYGIENE 

or  the  attractive  part  of  the  grounds ;  and  the  view  is  often  limited 
to  a  high  board  fence  or  unattractive  chicken  pens.  It  does  fix 
(more  than  we  realize)  the  type  of  individual  willing  to  work  as 
kitchen  helpers. 

Food  Problems. — ^Too  often  the  kitchen  employee  is  mentally 
and  instinctively  lacking  in  appreciation  of  the  niceties  necessary 
in  the  handling  of  foods,  and  often  herself  a  carrier  of  disease 
(typhoid,  dysentery,  tooth  and  gum  diseases);  these  make  her  a 
double  menace  to  the  family. 

Dirty  sinks,  food  trays  and  floors  attract  insects,  Croton  bugs 
and  flies  from  neighboring  apartments  or  houses,  including  toilets 
and  privies.  Eatchens  should  be  screened  and  kept  free  from  water 
bugs,  cockroaches,  etc.  (see  Appendix).  Mice  may  be  dangerous, 
and  the  conveyance  of  typhoid  by  rats  from  an  infected  sewer  has 
been  demonstrated.  ISTo  one  willingly  eats  food  after  such  unclean 
animals  have  travelled  over  it,  and  it  should  be  made  impossible. 

The  preparation  of  food  involves  the  greatest  consideration  for 
others.  Licking  the  fingers,  handling  the  handkerchief,  using  the 
dish  towel  as  a  hand  towel  or  napkin,  dipping  the  tasting  spoon 
back  into  the  food,  are  a  few  of  the  habits  all  too  common,  whether 
servants  or  members  of  the  family  handle  the  food.  How  disgust- 
ing it  is,  they  usually  do  not  realize,  though  they  would  be  grossly 
insulted  if  one  made  such  statement  as,  "  This  delicious  meal  you 
are  serving  contains  30  deposits  of  saliva  or  nasal  excretions.^'  Such 
offenders  are  often  otherwise  very  dainty  in  food  service.  More 
than  one  housekeeper  '"  cannot  understand  why  X  never  will  stay 
to  dinner." 

Every  effort  should  be  made  to  remove  the  results  of  careless 
handling  by  others.  Careless  grocery  and  milk  delivery  men  often 
touch  food  with  their  hands  which  cannot  help  but  be  soiled  with 
objectionable  material  {e.g.,  by  reins  which  too  often  fall  down  into 
the  dirty  street).  Most  food  materials  are  sold  in  packages,  or  pro- 
tected by  paper  covers,  or  are  washed  or  cooked  before  using;  but 
unwrapped  bread  is  too  often  carried  in  soiled  hands  or  against 
soiled  clothing,  or  piled  on  the  floor  of  wagons  on  which  the  driver 
often  steps  with  street-soiled  shoes.  Milk  bottles  are  almost  always 
carried  by  the  rim,  over  which  the  milk  must  be  poured.  Milk 
bottles  should  be  washed  thoroughly  before  the  top  is  removed,  pay- 
ing special  attention  to  the  rim  itself.    If  the  rim  is  wiped  dry,  it 


THE  HOME  235 

should  be  done  with  a  bit  of  clean  paper  towel  or  with  an  unused 
cloth — not  with  the  dish  cloth. 

Vegetables  that  are  eaten  raw  should  be  thoroughly  rubbed  or 
scraped,  and  rinsed  in  several  waters.  Lettuce  and  celery  are  very 
difficult  to  clean  (Fig.  67).  Typhoid  cases  have  been  traced  to 
lettuce,  and  the  habit  of  adding  human  excreta  to  truck  gardens  is 
fraught  with  danger.  Typhoid  has  been  experimentally  recovered 
from  lettuce  months  after  such  addition  to  garden  soil. 


Fig.  67. — Some  of  the  water  used  in  washing  lettuce  was  added  to  this  plate  of  agar;  the 
above  indicates  the  need  for  thorough  washing  of  such  vegetables. 

The  Icebox. — The  icebox,  too,  has  its  problems.  If  old  (and 
most  people  economize  on  the  kitchen  and  its  equipment  more  than 
elsewhere),  it  may  have  much  wet,  musty  wood  in  it.  Broken  tops 
or  doors  carelessly  left  open  raise  the  temperature.  To  "save 
ice/^  newspapers  are  sometimes  wrapped  about  the  ice,  ignoring  the 
fact  that  the  inclosed  air  and  food  are  cooled  only  as  they  give  up 
their  heat  to  melt  the  ice.  It  saves  ice,  but  helps  turn  the  icebox 
from  a  refrigerator  into  an  incubator.  Finding  a  favorable  tem- 
perature, bacteria  multiply  rapidly  in  such  substances  as  milk,  and 


236  HOME  AND  COMMUNITY  HYGIENE 

we  wonder  "  why  it  soured  iu  the  refrigerator."  Most  iceboxes  do 
not  provide  a  lower  temperature  than  1U°  C.  (50°  F.)  and  every 
effort  should  be  made  to  keep  it  down  to  that  temperature. 

The  ice  chamber  is  a  better  place  for  milk  bottles  than  the 
shelves,  and  it  is  wiser  to  cool  the  drinking  water  in  similar  bottles 
than  to  put  ice  into  the  water. 

Many  foods  absorb  odors;  milk  and  butter  are  affected  by  tur- 
nips, strawberries,  bananas,  etc.  It  may  be  necessary  to  guard 
against  such  odors  as  well  as  the  musty  odors  of  old  food  or  water- 
soaked  wood  or  icebox  linings. 

Water  Coolers. — The  best  water  coolers  have  separate  compart- 
ments for  the  ice,  so  that  the  careless  handling  by  icemen  is  a 
matter  of  less  concern.  If  ice  ever  comes  in  contact  with  the  foods 
(salads,  cooling  drinks)  one  should  make  sure  that  the  effects  of 
handling  (manure,  soiled  hands,  dragging  over  dirty  pavements) 
are  washed  off  as  well  as  can  be  done  before  the  ice  is  put  into  the 
refrigerator.  It  is  very  difficult,  but  very  important,  to  secure  such 
cooperation  in  kitchen  and  delivery  service.  Most  water  coolers 
have  .a  very  short  faucet,  or  a  leaky  faucet  (Fig  87),  making  it 
difficult  to  secure  a  glass  of  water  free  from  finger-washed  drippings 
(see  p.  278).  A  common  cup  should  not  be  provided,  even  if  the 
members  of  the  household  are  all  free  from  Eiggs  disease  of  the 
teeth  and  gums,  venereal  disease,  and  intestinal  diseases,  for  com- 
mon colds  are  too  easily  spread  in  that  way  to  make  it  desirable  to 
continue  the  common  drinking  cup  in  the  home. 

House  Filters. — House  filters,  as  described  in  the  chapter  on 
water,  are  usually  worse  than  useless.  The  kind  of  care  house  filters 
usually  receive  makes  inadvisable  the  use  of  any  but  a  cotton  pad 
filter.    The  pad  is  renewed  at  least  once  a  day  (see  Chapter  V). 

Plumbing. — The  bathroom  and  kitchen  nowadays  share  that 
mysterious  blessing,  "  modern  plumbing."  When  one  makes  a 
mystery  of  such  simple  facts  as  "  heated  water  rises,"  or  such  simple 
mechanical  principles  as  the  siphon,  modern  plumbing  is  indeed 
hard  to  understand. 

Every  user  of  modern  plumbing  should  understand  the  main 
features  of  its  use  in  our  homes.  There  are  two  distinct  parts :  ( 1 ) 
the  incoming  water  system  delivering  hot  and  cold  water  at  the 
various  faucets;  and  (2)  the  outgoing  pipes  containing  water  and 
the  more  or   less  liquid   waste   from   the   kitchen,  bathroom,   and 


THE  HOME  237 

laundry.  Open  plumbing,  that  is,  plumbing  exposed  to  view,  is 
most  desirable  for  the  following  reasons :  better  workmanship  is  usu- 
ally received,  leaks  are  more  promptly  detected,  and  repairs  are  both 
simpler  and  less  expensive.  If  the  plumbing  is  in  recesses,  the 
protecting  woodwork  should  be  screwed  instead  of  nailed  in  place, 
or  otherwise  easily  removed.  The  dark  plumbing  recesses  are  usu- 
ally moist,  and  make  hiding  places  for  insect  pests. 

The  Water  System. — Beyond  the  fact  that  the  water  pipes 
may  open  out  into  special  tanks — storage  tank  on  the  roof  to  in- 
sure good  pressures  at  all  levels  throughout  the  house,  the  toilet  tanks 
to  insure  a  sufficient  amount  of  water  for  flushing  purposes,  the 
hot-water  boiler  holding  water  which  becomes  heated  because  the 
pipe  feeding  the  boiler  passes  first  through  the  furnace  or  over  a 
gas  flame — there  is  little  in  the  water  service  that  is  difficult  to 
understand.  The  main  problems  are  leaky  faucets,  leaky  joints,  and 
frozen  pipes.  The  first  two  lead  to  loss  of  water,  water-soaked 
corners  or  floors,  or  damp  cellars,  and  usually  demand  the  services 
of  a  plumber,  though  there  is  now  a  type  of  water  faucet  that  can 
be  repaired  by  a  non-expert. 

Frozen  Pipes. — Frozen  pipes  do  not  always  burst.  Moderate 
general  heat  should  be  applied  by  wet  cloths  on  the  pipes,  or  oil 
stoves  or  even  lamps  should  be  placed  near  by.  Do  not  apply  con- 
centrated heat,  such  as  a  flame,  at  one  point,  but  with  wet  cloths 
thaw  the  faucet,  and  work  back  and  down  until  you  have  reached 
the  source  of  the  trouble.  Leave  the  faucet  open  to  allow  the  ex- 
panding water  to  escape  that  way,  or  the  pipes  may  burst.  (Cold 
water  expands  as  it  nears  the  freezing  point,  4°  to  0°  C.  (39°  to 
32°  F.)  So  there  are  two  chances  for  your  water  pipes  to  burst: 
one  as  they  freeze,  and  one  as  they  thaw  and  the  water  becomes 
warmed.  If  possible,  gradually  raise  the  temperature  of  the  room 
or  cellar  where  the  freezing  occurred,  so  as  to  prevent  extension  of 
the  frozen  area.  Frozen  pipes  ^  can  generally  be  cared  for  without 
a  plumber.  When  pipes  freeze  in  one  house,  they  are  usually  frozen 
in  other  houses,  and  plumbers  are  much  in  demand.  Every  mem- 
ber of  the  household,  however,  should  know  just  where  the  water 

^  Frozen  waste  pipes  hurst  less  often  than  frozen  water  pipes.  Waste 
pipes  contain  hut  little  liquid  material  (traps,  etc.),  and  as  that  freezes 
it  finds  the  necessary  room  for  expansion  hy  compressing  the  elastic  air 
which  fills  most  of  the  pipe. 


238 


HOME  AND  COMMUNITY  HYGIENE 


enters  the  house,  so  as  to  turn  it  off  in  any  emergency,  as  in  case  of 
a  leak  or  a  broken  pipe.  There  is  little  excuse  for  sitting  in  increas- 
ing iloods  of  water  while  someone  hunts  for  a  plumber.  Hot-water 
pipes  freeze  and  burst  more  readily  than  cold-water  pipes.  This  is 
due  to  the  fact  that  there  is  more  air  in  cold  water  than  in  heated 
water.    Ice  crystals  form  more  slowly  in  water  containing  air. 


Fig.  68. — A  simple  trap,  the  S-trap.  At  the  bottom  of  the  curve  is  an  opening  through 
which  grease,  etc.,  can  be  removed.  When  water  enters  from  the  sink,  a  continuous  column 
of  water  is  formed;  this  siplions  over,  leaving  the  last  of  the  water  in  the  trap  as  a  seal, 
as  shown. 

House  Waste  Systems. — The  disposal  system  is  more  com- 
plicated than  this,  however.  Every  waste  pipt.  from  sink,  bathtub, 
wash  basins,  toilets,  and  laundry  tubs  has  in  it  one  or  more  bends 
called  traps  (Fig.  74).  These  traps  are  of  various  styles  (Figs. 
68  and  69),  but  they  are  all  designed  to  prevent  the  gases  from  the 
'drains  and  sewers  from  coming  up  into  the  house.  Where  these 
outflow  pipes  enter  a  main  or  larger  drain  pipe,  another  trap  is  usu- 
ally found  to  prevent  any  gas  from  that  main  pipe  from  coming 
back  into  the  house.    When  all  these  outlets  have  been  collected  into 


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239 


one  large  drain,  another  trap  is  usually  found  just  as  that  drain 
leaves  the  house  and  empties  into  the  sewer.  So  between  the  street 
sewer  and  any  fixture  there  are  often  three  traps. 

The  S-trap  (Fig.  68)  is  the  simplest  kind,  but  of  the  several 
other  types  the  commonest  is  the  bell-trap  (Fig.  69),  often  used 
in  floor  drains  and  in  old-fashioned  kitchen  sinks.  If  the  kitchen 
sink  is  not  washed  out  after  the  dirty  water  passes  from  it,  soiled 
water  is  left  in  the  trap  and  odors  from  that  soiled  water  may  be 
noticed.     In  houses  left  for  several  months  in  summer  the  water 

^ct  ■»•  c  M  I  «  X    jtrai-nev     top 


bohtoTn  o/  5tTiH 


■*>*<!»  ter    5eal 
Of  trap 


FiG.  69. — A  bell-trap,  used  in  old-style  sinks,  also  common  in  floors  of  shower  baths,  garages, 
etc.    The  water  seal  is  a  circular  area  into  which  the  circular  edge  of  the  bell-top  fits. 

in  the  traps  may  evaporate  and  allow  odors  to  come  back  into  the 
houses.  Fixtures  should  be  flushed  periodically  by  the  caretaker; 
or  the  trap  can  be  preserved  by  a  film  of  oil  which  spreads  out 
readily  on  the  surface,  preventing  evaporation.  Glycerin  might  be 
used  because  of  its  water-holding  power,  which  prevents  evapora- 
tion, and  may  even  attract  water  from  the  moist  atmosphere. 

Another  difficulty  with  traps  is  that  they  may  be  thrown  out  of 
order  (emptied,  clogged)  by  foreign  matter  (Fig.  70).  An  open- 
ing is  left  in  most  traps  through  which  they  can  be  cleaned  out 
(Fig.  68).  Often  valuable  objects  {e.g.,  jewelry)  washed  down  a 
waste  pipe  can  be  recovered  from  the  trap.  Opening  the  trap, 
though  not  pleasant,  is  not  a  difficult  job,  and  does  not  necessarily 
demand  the  services  of  a  plumber.     Grease  from  the  kitchen  sink, 


240 


HOME  AND  COMMUNITY  HYGIENE 


especially  if  cold,  often  fills  up  the  curve.  Accumulations  of 
grease  sufficient  to  clog  a  pipe  may  be  due  to  carelessness  and  waste 
in  the  kitchen.  Often,  however,  it  is  due  to  poor  plumbing.  If 
the  main  drain  pipe  into  which  branch  pipes  empty,  is  too  large,  th? 


vvJ 


Fig.  70. — String,  etc.,  catching  in  traps  may  carry  the  water  over,  until  the  water  is  too  low 

to  act  as  a  seal;  objectionable  odors  then  pass  back  and  up  into  the  house. 

flow  is  retarded  by  the  friction  which  a  relatively  greater  surface 
causes,  and  grease  may  be  deposited;  usually  it  is  scraped  off  by 
the  action  of  small  particles  in  the  moving  current.  If  the  main 
drain  pipe  is  too  small,  passage  is  also  retarded,  and  grease  may 

Fig.  71.  Fig.  72. 


Fig.  71. — A  "wash  out"  closet;  the  words  "wash  out" refer  to  the  washing  out  of  the 
bowl.  The  trap  is  made  by  the  water  below  (L).  If  the  point  P  is  very  short  as  shown 
here,  the  seal  is  not  very  good,  and  is  "broken"  if  a  little  water  evaporates,  as  in  houses 
closed  for  the  season. 

Fig.  72. — A  "wash  down"  closet;  this  has  no  upper  chamber  of  water.  Thetrap  is 
better  than  in  Fig.  71,  because  the  point  P  is  longer. 

collect  in  the  traps.  Sal  soda  (1  part  to  10  of  water)  may  be  used 
to  clean  out  grease-retarded  pipes.  If  this  does  not  remove  the 
difficulty,  use  lye  or  caustic  soda,  making  a  saturated  (G)  solution, 
and  diluting  with  an  equal  amount  of  water;  a  pint  to  a  quart 


THE  HOME 


241 


should  be  poured  into  the  sink.  The  pipes  should  be  flushed  thor- 
oughly with  hot  water  afterward  (as  lye  is  a  little  "hard"  on 
plumbing).  With  careful  use  house  sinks  may  be  used  for  years 
without  ever  having  to  have  the  grease  trap  opened. 

Three  types  of  water  closets  are  shown  here  (Figs.  71,  72,  and 
73).  Each  contains  a  water  seal;  the  differences  lie  chiefly  in  the 
method  of  flushing. 

Traps  and  Sewer  Gas. — Sewer  gas  is  continually  being  formed 
in  the  sewage,  and  while  we  now  know  it  cannot  cause  disease,  such 
odors  are  unpleasant.    To  make  sure  that  they  do  not  break  through 


Fig.  73. — A  "siphon  closet"  in  which  the  siphon  action  ia  better;  the  little  bend  near 
the  floorin  the  outflowingpipe  slows  the  outflow,  and  both  sides  of  the  curved  outflow  pipe 
become  filled  with  material,  making  a  siphon  which  sucks  out  practically  all  of  the  original 
material ,  leaving  only  fresh  clean  water  in  the  trap .  The  siphon  action  is  more  complete  in 
such  types. 

the  trap  or  water  seal,  a  pipe  leads  off  from  the  back  of  the  toilet  and 
from  the  back  of  the  main  house  drain,  into  a  special  vent  pipe  that 
runs  up  through  the  house  and  opens  one  to  two  feet  above  the  roof 
(Fig.  74).  Any  gases  working  back  along  a  drain  find  it  easier  to 
go  on  up  the  vent  pipe  branch  than  to  push  through  the  water  seal. 

The  practice  of  keeping  a  fine  wire  sieve  in  the  kitchen  sink  to 
screen  the  vegetable  water,  etc.,  is  a  good  one.  There  is  no  excuse, 
however,  for  the  soggy  brushes  often  seen  there.  If  a  brush  is 
necessary  for  occasional  cleaning  of  the  sink,  it  should  be  dried 
thoroughly  (outdoor  sunshine  or  radiator)  and  kept  dry  until  used 
again.  It  is  much  better  to  have  a  roll  of  paper  towels  hanging 
near  the  sink,  using  a  couple  of  pieces  to  clean  out  particles  of 
waste,  preparatory  to  the  final  rinsing  of  the  sink. 

Bathroom:  Care  and  Equipment. — Toilets  should  be  kept 
clean  and  filled  with  the  amount  of  water  called  for  by  the  tank. 
16 


242 


HOME  AND  COMMUNITY  HYGIENE 


It  is  not  a  good  plan  to  lessen  the  tank  outflow  by  bending  the 
attachments  in  the  tank,  as  the  depth  of  the  water  in  the  bowl  is 
adapted  to  the  type  of  trap.  Toilet  traps  are  often  hidden  from 
sight,  especially  in  some  of  the  porcelain  stands,  but  they  are  always 
present  (Fig.  71).  Outdoor  privies  are  discussed  under  sewage 
disposal  (also  p.  251). 

Colds,  sore  throat,  grip  and  other  infectious  diseases  are  easily 
transferred  by    unclean    faucet    handles,  doorknobs,    toilet   flush 


oor  level 


Fig.  74. — Closets  may  have  a  double  trap,  as  shown  here.  The  second  (lower)  trap 
slows  the  emptying  process,  and  improves  the  siphonic  action.  This  cut  shows  also  the 
vent  (v)  customarily  placed  in  traps  to  allow  any  back-pressing  gases  to  escape  into  a  special 
set  of  pipes  (vent  pipes)  opening  on  the  roof;  since  these  air  or  vent  pipes  offer  less  resistance 
than  the  water  in  the  traps,  the  gas  escapes  that  way  without  "breaking  the  seal." 


handles,  and  other  bathroom  fixtures.  They  should  be  regularly 
and  frequently  cleaned.  Individual  towels,  wash  cloths,  and  hand- 
kerchiefs should  be  supplied  for  each  member  of  the  family,  no 
matter  how  young.^  Squares  of  cheesecloth  or  old  white  goods, 
kept  for  colds  and  such  emergencies,  can  be  burned,  thus  eliminat- 
ing washing.  The  frequent  washing  of  hands  should  be  made  easy 
— with  lavatories  on  each  floor,  for  example,  especially  if  there  is 

^  Few  who  read  this  will  realize,  probably,  how  many  people  now 
living  have  never  considered  such  things  necessities,  and  how  impossible 
a  standard  this  is  for  many,  many  families.  A  world  in  which  millions 
find  it  difficult  and  even  impossible  to  escape  hunger  and  cold  will  include 
more  still  who  are  never  clean. 


THE  HOME  243 

but  one  bathroom  for  the  whole  family.  Paper  towels  will  often 
tide  over  an  emergency,  when  the  prospect  of  an  unusually  large 
wash  would  make  one  choose  the  less  desirable  method  of  sharing 
towels.  After  washing,  if  one  has  a  cold  or  sore  throat,  the  bowl 
should  be  flushed  with  hot  water,  and  a  clean  piece  of  paper  used 
to  turn  the  faucets,  etc.,  that  another  well  member  of  the  family 
will  soon  touch.  A  little  alcohol,  ammonia,  or  other  suitable  dis- 
infectant may  well  be  rubbed  over  such  attachments  after  use  by 
one  having  a  cold  or  sore  throat  (see  p.  189). 

The  water  closet  itself  is  often  quite  a  problem.  Chance  visitors 
to  the  bathroom  may  leave  one  uncertain  as  to  the  safety  of  the 
appliances  used.  Good  soapsuds  is  a  safe  measure,  but  that 
sometimes  may  not  be  at  hand.  Kerosene  or  gasoline,  if  there  is 
no  free  flame  in  the  bathroom  {e.g.,  gas  jet,  oil  heater)  makes  a 
good  emergency  wash  that  will  not  injure  the  finish  on  most  seats. 
Boarding  houses  and  hotels  should  have  adjustable  paper  seats  (cut 
newspaper  will  do)  with  a  waste  basket  for  receiving  them. 

Every  effort  should  be  made  to  have  hotels  and  boarding  houses 
substitute  the  sanitary  shower  for  the  bath  tub,  which  too  often  is 
not  properly  cleaned  before  using.  Serious  infections  have  been 
traced  to  its  use.  Bath  tubs  should  be  thoroughly  washed  with  hot 
soapy  water,  and  rinsed  with  plenty  of  hot  water  *  before  they  are 
used.  The  practice  of  having  baths  drawn  by  careless  or  infected 
servants  is  not  without  danger.  Among  members  of  the  same  family 
there  is  less  often  unwitting  transfer  of  disease  through  bath  tubs ;' 
too  commonly,  however,  the  one  tub  must  be  shared  with  others 
about  whom  less  is  known :  servants,  guests,  and  boarders.  In  such 
cases  a  shower  bath  is  certainly  preferable. 

Bathrooms  and  toilets  should  be  aired  thoroughly,  though  the 
night  temperatures  should  be  such  that  no  chill  is  felt  by  night 
visitors.  The  bathroom  is  often  so  poorly  heated  in  winter  that 
bathing  becomes  a  moral  issue.  Everyone  in  charge  of  a  home  must 
make  such  provisions  for  personal  cleanliness  as  are  necessary  for 
the  health  and  general  well-being  of  its  members.  At  times,  in- 
sistence as  well  as  provision  may  be  necessary.  If  the  bathrooms 
are  not  comfortably  warm,  bathing  may  be  too  cursory  or  too  in- 
frequent; although  we  know  now  that  bathing  is  not  absolutely 

*  Clean  cloths  are  better  for  this  purpose  than  the  wet  soggy  brushes 
conunonly  used. 


244 


HOME  AND  COMMUNITY  HYGIENE 


necessary  for  health,  there  are  still  strong  arguments  in  its  favor: 
bathing,  especially  if  followed  by  a  cold  shower  or  plunge,  has  a 
stimulating  effect  upon  the  skin  and  improves  its  important  func- 
tion as  a  regulator  of  body  temperature.  It  gives  a  sense  of  relaxa- 
tion and  rests  the  body  more  than  any  other  process  except  mas- 
sage. Not  the  least  of  its  values  is  the  sense  of  cleanliness  and 
general  well-being. 

Methods  of  Cleaning. — The  day  of  the  feather  duster  has 
passed,  but  not  all  of  the  dust-raising  processes  have  shared  the 
same  fate,  unfortunately.    Lint-producing  carpets  are  still  too  com- 


FiG.  75. — Plates  were  exposed  for  five  minutes  each  in  a  room  following  the  type  of  sweeping 
or  cleaning  indicated  below  each  plate. 

mon;  so  is  dry  sweeping  (Fig.  75).  The  dry  dust  cloth  is  still 
used  unquestioningly  by  many  (Fig.  76).  True,  the  stores  adver- 
tise dustless  dust  cloths,  but  they  are  fairly  expensive,  and  used 
for  far  too  long  a  period  without  replacement  or  washing.  It  would 
be  much  better  to  saturate  old  rags  with  a  little  water,  a  little 
kerosene,  or  a  little  furniture  polish  (whichever  the  type  of  articles 
to  be  dusted  demands),  and  make  a  number  of  dustless  cloths  which 
could  be  used  and  washed  often — daily,  and  dried  thoroughly  in 
the  sun  (or  on  rainy  days  near  the  furnace  or  range).  Bugs  not 
only  have  a  less  lint-producing  surface  than  carpets,  but  they  are 
more  easily  handled,  and  consequently  aired  and  cleaned  oftener. 
The  carpetless  edges  and  corners  of  the  room  show  the  dust  more 


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245 


promptly  than  if  covered  with  carpet,  but  it  is  easily  removed 
and  is  removed  oftener  and  more  completely  than  from  carpets.  A 
little  more  attention  might  well  be  paid  to  the  dust-  or  lint-making 
character  of  the  materials  used  for  floor  coverings. 

The  vacuum  cleaner  (Fig.  75)  should  replace  the  broom  when- 
ever the  family  income  makes  it  possible.  Efficient  daily  and 
weekly  cleaning  with  such  aids  makes  the  yearly  turmoil  called 
spring  housecleaning  unnecessary,  except  as  a  stimulus  for  discard- 
ing accumulations  of  useless  materials. 


Fig.  76. — Dusting  by  three  different  methods  as  indicated. 

Floors. — In  cleaning  floors  a  clean  cloth  slightly  moistened 
with  kerosene  (or  a  more  inert  oil)  should  be  used  occasionally  to 
remove  dirt,  if  water  is  harmful  to  the  type  of  floor.  Water  in 
small  amounts  can  often  be  used  safely,  if  removed  quickly  and 
thoroughly.  Oil  and  wax  tend  to  hold  dust  and  lint,  and  keep  the 
air  less  loaded  with  such  suspensions.  It  is,  nevertheless,  desirable 
occasionally  to  clean  or  even  scrape  such  coated  floors  and  start 
afresh. 

Dishes. — ^The  cleaning  of  dishes  is  often  most  incompletely 
done.  Soapless,  dirty  dishwater  is  most  common.  Scraps  should 
be  removed  from  the  plates  before  the  dishes  are  put  into  the  dish- 


246  HOME  AND  COMMUNITY  HYGIENE 

pan.  Kinsing  at  the  faucet,  to  remove  such  material,  is  a  good 
plan.  If  running  water  is  not  available  or  is  limited  in  amount,  the 
plates  should  be  carefully  scraped  or  even  wiped  with  bits  of  paper. 
This  not  only  keeps  the  dishwater  in  better  condition,  but  removes 
grease,  etc.,  that  might  clog  the  drains.  There  is  no  excuse  for 
wishing  dishes  in  water  that  suggests  garbage.  A  lather  is  neces- 
sary to  completely  remove  the  bits  of  food  or  mucus  from  the 
dishes.  There  is  every  reason  why  glasses  and  silver  should  be  as 
thoroughly  washed  in  soapy  water  and  rinsed  in  very  hot  water  as 
any  other  dishes;  more  so,  because  they  come  more  directly  into 
contact  with  the  mouth  than  anything  else,  except  the  teacups  and 
spoons.  It  is  a  very  common  practice  to  treat  dishes  that  look 
clean,  e.g.,  drinking  glasses,  as  if  they  were  clean,  rinsing  them 
without  washing.  Just  as  objectionable  is  the  habit  of  never  rins- 
ing the  glasses  at  all.  We  wash  dishes,  rubbing  especially  soiled 
parts  (edges  of  glasses)  to  loosen  saliva  and  food  particles  from 
them,  but  even  so,  rinsing  is  always  necessary.  Wash  water  and 
rinsing  water  should  both  be  changed  often,  if  the  number  of  dishes 
is  large;  neither  should  be  used  when  it  is  dirtier  than  the  dishes 
put  into  it.  Many  times  dishes  (such  as  teapots)  are  dirtier  after 
they  have  been  washed  than  they  were  before. 

Dish  Cloths  and  Towels. — Dish  cloths  and  dish  towels  should 
be  clean  and  fresh  smelling  and  washed  often,  preferably  after 
each  meal.  If  a  sufficient  number  of  dish  towels  are  in  use,  and 
they  are  dried  thoroughly  after  using,  once  a  day  may  be  sufficient. 
Dish  cloths  should  never  be  left  in  a  wet  ball  or  wad  in  the  sink 
or  hung  in  a  dark  place  {e.g.,  under  the  sink),  but  they  should  be 
washed  and  rinsed  as  thoroughly  as  the  towels  and  dried  after  every 
meal.  If  dish  mops  are  necessary  because  of  the  sensitiveness  of 
the  washer's  hands  to  water,  more  than  one  mop  should  be  pro- 
vided, and  they  should  be  washed  and  rinsed  thoroughly,  and 
opened  out  while  drying  so  that  the  sun  can  penetrate  the  threads. 

Pans  and  Kettles. — Sufficiently  soapy  water  will  not  leave  a 
rim  of  black  grease  on  the  dishpan.  A  dishpan  should  be  as  clean 
as  any  other  pan,  and  should  be  as  useful  in  any  emergency  {e.g., 
washing  lettuce)  as  any  other  pan.  The  only  reason  (except  con- 
venient size)  for  using  a  dishpan  for  dishes  only  is  that  it  is  too 
dirty  for  other  purposes,  which  is  in  itself  an  admission  we  should 
be  loth  to  make.    Pots,  pans,  and  kettles  should  be  as  clean  as  the 


THE  HOME  247 

dishes,  and  washed  and  rinsed  as  thoroughly.  Where  wood  or  kero- 
sene is  used  for  fuel,  such  utensils  become  blackened  on  the  outer 
surfaces,  but  the  inside  should  be  as  clean  as  any  dish  used  on  the 
table. 

Personal  Articles. — Handkerchiefs,  towels,  etc.,  of  the  mem- 
bers of  the  family  suffering  from  any  contagious  disease  (cold, 
sore  throat,  grip,  measles)  should  be  boiled  in  soapy  water  before 
they  are  handled  by  the  one  doing  the  washing.  Washing  in  hot, 
soapy  water,  and  the  subsequent  boiling,  followed  by  drying  in  the 
air  and  sun,  render  clothes  not  only  clean  but  safe.  Ironing  is  also 
of  value  in  killing  any  objectionable  organisms.  Clothes  washed 
away  from  home  are  often  not  boiled  at  all,  and  too  often  in  bad 
weather  they  are  dried  indoors.  If  infected  members  of  the 
laundress's  family  help  in  the  later  processes  {e.g.,  folding  the 
ironed  clothes),  there  is  a  little  danger  that  tubercular  or  venereal 
infections,  if  present,  may  be  transferred.  There  is  no  reason  to 
think  that  disease  organisms  survive  thorough  washing  and  drying 
in  the  sun.  Ironing  kills  undesirable  bacteria,  but  it  is  done  for 
appearance  mainly ;  where  time  and  money  are  a  real  consideration, 
it  would  be  better  to  dispense  with  ironing  for  many  articles  and 
expend  that  time  or  money  in  securing  better  washing  conditions 
and  results  (see  p.  280).  The  clean,  attractive  odor  of  sun-dried 
sheets  is  really  not  improved  by  the  subsequent  dampening  and 
ironing. 

House  Disinfectants. — Under  cleaning  no  disinfectants  were 
given  for  the  treatment  of  the  sink  and  toilet.  Soap,  good  clean 
water,  air,  and  sunshine  are  all  that  good  plumbing  needs.  Sour, 
musty  or  foul  odors  indicate  leaks  or  breaks,  and  demand  the  im- 
mediate services  of  a  plumber.  A  deodorizer  would  but  hide  the 
real  condition  temporarily  and  give  a  false  idea  of  security. 

Disinfection  during  and  after  sickness  is  treated  in  a  separate 
chapter  (see  Chapter  X)  ;  dishes  and  other  objects  coming  in  con- 
tact with  infected  people  should  be  treated  as  described  in  that 
same  chapter  (see  Appendix). 

Insect  Pests. — Objectionable  insects  are  too  common.  ISTo 
housekeeper  publishes  abroad  the  fact  that  vermin  infest  the  beds 
and  clothing,  and  sometime  we  will  wage  as  earnest  a  warfare 
against  flies,  croton  bugs,  and  sow — or  pill — bugs  as  against  bed- 
bugs. Their  presence  usually  indicates  unsanitary  conditions  (food 
accumulations,  wet  or  moldy  woodwork),  and  may  lead  to  the  trans- 


248  HOME  AND  COMMUNITY  HYGIENE 

fer  of  disease  organisms — typhoid,  fly;  tuberculosis  (?),  bedbug 
(see  Appendix). 

Household  Pets. — Pets  in  the  household  are  difficult  to  discuss 
adequately.  Eabbits,  chickens,  and  similar  pets  kept  outdoors,  and 
birds  rarely  have  diseases  transferable  to  man.  They  are  handled 
less  than  such  indoor  pets  as  cats  and  dogs,  and  hands  are  more 
likely  to  be  washed  before  eating,  etc.,  so  that  there  is  little  objec- 
tion to  such  pets,  if  their  quarters  are  kept  free  from  objection- 
able odors  and  accumulations.  With  dogs  and  cats,  most  intimate 
indoor  companions  usually,  the  situation  is  very  different.  Both 
cats  and  dogs  are  susceptible  to  whooping  cough;  cats  have  been 
known  to  carry  diphtheria  in.  their  throats;  dogs  harbor  a  tape- 
worm and  several  less  common  worms  transferable  to  man.  Their 
proneness  to  haunt  accumulations  of  refuse  and  offal,  and  their 
intimate  association  with  the  household  inmates,  nosing  the  food, 
licking  the  hands,  stepping  or  lying  on  cushions,  beds,  etc.,  make 
such  direct  transfer  unpleasant  in  idea  if  not  actually  elements  of 
danger.  While  there  is  less  danger  in  drinking  after  a  dog  than  a 
human  afflicted  with  venereal  disease,  it  is  not  a  necessary  alter- 
native, and  should  not  be  presented  as  such.  The  danger  from 
rabies  is  not  slight,  and  every  one  owes  it  to  the  community  so  to 
control  his  dog  (muzzling,  confining  to  enclosed  yard)  that  he  does 
not  add  to  the  disgraceful  prevalence  of  rabies  in  this  country. 
Other  countries  (England,  Australia)  have  practically  stamped  out 
rabies  and  demand  a  long  quarantine  period — several  months — of 
any  dogs  brought  into  their  countries.  We  ought  to  have  a  nation- 
wide law  requiring  muzzling  of  all  dogs  for  two  years ;  after  that  a 
strict  quarantine  law  on  imported  dogs  would  be  sufficient. 

It  is  rare  nowadays  that  dogs  or  cats  perform  any  real  service 
(mice,  rats)  not  more  efficiently  and  cheaply  done  by  traps,  poisons, 
etc.;  cats  yearly  destroy  more  insect-destroying  birds  than  their 
mousing  records  can  balance. 

It  is  time  to  look  this  matter  squarely  in  the  face,  and  admit 
(1)  that  our  insistence  upon  dogs  and  cats  as  pets  is  mainly  a 
matter  of  personal  pleasure,  for  we  enjoy  the  feeling  of  companion- 
ship and  the  grateful  recognition  of  mastery  and  benefits  bestowed ; 
and  (2)  that  these  sensations  would  be  equally  satisfied  if  other- 
wise homeless  children  took  the  place  of  dogs  and  cats.  Only  a 
very  selfish  person  can  support  the  claims  of  dogs  and  cats  against 
those  of  children. 


THE  HOME  249 

PROBLEMS 

1.  Describe  the  daily  cleaning  methods  in  use  in  your  home.  The 
methods  in  use  in  your  church?     Give  their  good  and  bad  points. 

2.  Is  money  or  thought  more  necessary  in  improving  your  home  methods 
of  floor  cleaning?  Dish  washing?  Dusting?  Calculate  the  extra  time 
or  extra  money  (e.g.,  soaps)  it  would  take  per  week  or  month  to  perform 
one  of  the  home  cleaning  processes  in  a  way  you  would  like  to  have  adopted. 

3.  The  statement  is  often  made,  "It  costs  money  to  be  clean."  How 
much  does  it  cost  per  year  for  soap,  hot  water,  scrubbing  brushes,  towels, 
etc.,  for  each  person  in  your  family? 

4.  What  is  the  relative  hygienic  importance  of  (1)  fresh  air,  (2) 
dustless  rooms,  and  (3)  hygienic  handling  of  food  and  dishes?  Which 
receives  the  greater  emphasis  in  your  home?  The  least?  Illustrate  by 
the  type  of  person  performing  the  related  tasks,  the  time  devoted  to  each, 
and  the  actual  cost   (apparatus,  utensils,  etc.). 

5.  There  is  probably  very  little  danger  in  eating  food  that  has  dropped 
on  the  floor.  The  organisms  thus  picked  up  are  unlikely  to  be  harmful 
ones.  Often  such  disadvantages  may  be  wholly  overcome;  e.g.,  by  wash- 
ing, cutting  off  outer  surfaces,  or  by  heating  or  cooking  ( toasting  bread ) . 
Show  why  it  may  be  dangerous  to  eat  candy  carried  loosely  in  the  hand- 
kerchief pocket  of  another;  or  to  lay  one's  tooth  brush  on  the  edge  of  the 
wash  basin  used  by  others  in  the  same  boarding  house. 

6.  What  provisions  regarding  racks  for  towels,  wash  cloths,  tooth 
brushes  and  soap  should  be  made  in  boarding  houses,  if  the  members  use 
a  common  bathroom?  Show  that  nails  and  extra  shelves,  for  temporary 
placing  of  glasses,  soap,  cups,  etc.,  and  a  paper  towel  supply  are  absolutely 
necessary  for  all  with  instincts  of  personal  cleanliness. 

7.  Modify  the  following  to  make  it  suitable  for  your  home.  It  should 
state  plainly,  but  without  undue  offence,  the  necessary  rules  or  recom- 
mendations. 

UNPLEASANT  TRUTHS  FOK  COOKS  AND  WAITEESSES 

Do  you  realize  that  one  little  unconscious  personal  habit  may  com- 
pletely destroy  all  pleasure  in  the  meals  you  take  such  pains  to  prepare  and 
serve  ? 

Would  you  like  your  cook  or  waitress  to  put  her  tasting  spoon  or 
fork  back  into  the  food? 

Would  you  keep  her  if  you  knew  that  when  she  prepared  salad  or  cut 
up  fruit  she  licked  her  fingers  instead  of  wiping  or  washing  them  ? 

Would  you  enjoy  having  her  cough  constantly  into  your  food?  Wipe 
your  soft-boiled  eggs  on  used  napkins?  Touch  the  drinking  edge  of  your 
glass  with  fingers  that  have  handled  soiled  handkerchiefs  or  other  articles 
of  clothing? 

Sore*  throats,  colds,  diseases  of  the  teeth  and  gums,  dysentery  and 
typhoid  may  be  conveyed  in  this  way.  Fully  as  important  is  the  esthetic 
aspect.  Why  spend  so  much  time  making  food  look  attractive  (fancy 
molds,  designs,  etc.)  when  one  careless  habit  may  render  it  all  absolutely 
repulsive  to  an  observant  person? 

See  Reference  List  at  end  of  Appendix. 


-»  CHAPTER  XIV 

SUMMER  CAMPS 

Ix  the  main,  the  health  problems  of  the  summer  camp  are  those 
of  the  ordinary  home.  This  is  true  whether  the  camp  is  a  tent,  a 
"  shack/'  an  isolated  permanent  cottage,  or  part  of  a  summer 
community. 

Camps  need  all  the  safeguards  mentioned  in  Chapter  XIII. 
Most  important,  also,  are  the  source  of  the  water,  the  restricted 
range  in  food  materials,  the  greater  danger  from  insect  pests,  and 
the  disposal  of  garbage  and  human  waste. 

Water. — In  mountainous  and  isolated  regions  the  water  supply 
may  sometimes  be  safely  taken  from  brooks  or  streams.  But  the 
dangers  of  pollution  by  hunters,  mountain  parties,  etc.,  must  be 
considered,  and  only  cistern,  spring,  or  well  water  should  be  used, 
unless  the  surface  water  is  chemically  treated  or  boiled  (see  Appen- 
dix). Lake  water  is  too  often  used  for  drinking  by  campers,  even 
though  that  same  lake  serves  also  for  bathing,  and  as  a  receptacle 
for  the  house  drainage.  Sufficient  dilution  and  the  other  factors 
mentioned  in  the  chapter  on  water  may  make  such  water  com- 
paratively safe,  but  it  is  hardly  a  pleasant  conception. 

The  numbers  sometimes  represented  in  boys'  or  girls'  camps  or 
overcrowded  summer  resorts  often  make  it  extremely  unlikel}^  that 
surface  water — even  when  taken  a  number  of  miles  upstream — is 
safe  from  human  pollution. 

To  fill  the  general  demand  for  opportunities  for  swimming, 
lakes  or  streams  far  from  safe  often  determine  the  site  of  the  camp. 
Most  State  boards  of  health  will  pass  upon  such  conditions  for 
prospective  members  or  managers. 

Disposal  of  Waste. — The  disposal  of  waste  is  also  quite  a  prob- 
lem. A  wire  basket  in  the  upper  part  of  the  fireplace  may  dry  out 
green  garbage  so  that  it  can  readily  be  burned,  or  a  wire  basket 
may  be  used  outdoors  as  an  incinerator.  Materials  in  it  would  dry 
250 


SUMMER  CAMPS  251 

out  fairly  well  if  not  too  tightly  packed;  a  little  kerosene  would 
insure  quite  complete  combustion.  In  localities  not  too  closely 
populated  nor  too  rocky  garbage  can  be  buried. 

Toilets. — The  toilet  offers  the  most  difficulty,  usually.  If  soft 
earth  or  ashes  are  available,  a  dirt  closet  is  perhaps  the  best  cheap 
way  of  solving  the  problem.  The  receiving  vault  should,  of  course, 
be  fly-proof,  and  emptied  whenever  necessary;  lime  may  be  used 
as  a  deodorizer,  mixing  it  with  the  earth;  if  sufficient  earth  be 
used,  lime  is  unnecessary.  The  vault  should  have  a  screened  area 
below  the  seat  level  to  help  in  ventilation.  Pail  closets  are  de- 
scribed on  page  149 ;  see  Chapter  VII  for  other  methods  of  sewage 
disposal. 

If  the  camp  is  a  house — not  a  tent — the  rainwater  can  be  col- 
lected and  used  for  laundry  and  toilet-flushing  purposes.  The  great 
tendency  to  save  on  water  for  cleaning  purposes  generally,  if  water 
must  be  carried,  makes  a  cistern  (if  mosquito-proof)  an  invaluable 
addition  to  the  summer  camp.  Cement  work  is  so  easily  done  that 
almost  any  man  can  construct  a  satisfactory  cistern;  wooden  tanks 
probably  offer  more  difficulties  to  the  amateur.  Simple  ingenious 
devices,  such  as  using  an  ordinary  garden  hose  between  the  tank 
and  the  privy  tank,  give  the  summer  resident  a  water  closet  at  a 
nominal  expense. 

Food. — The  restricted  range  in  food  materials  may  be  a  great 
drawback  to  certain  camp  sites.  Milk  is  unobtainable  in  some  sec- 
tions; clean,  safe  milk  not  common  in  most.  Green  vegetables  are 
often  very  scarce.  Housekeepers  with  prejudices  against  canned 
goods,  or  who  go  away  for  the  summer  to  economize,  often  provide 
most  insufficient  dietaries  for  their  families,  especially  the  chil- 
dren. This  is  one  of  the  criticisms  oftenest  made  against  camps 
for  boys  and  girls;  while  explainable,  as  they  are  usually  money- 
making  organizations,  it  indicates  a  lack  of  proper  supervision  on 
the  part  of  the  parents,  who  should  consider  the  dietary  provisions 
as  seriously  as  those  for  amusement  and  recreation. 

Insect  Pests. — The  danger  from  insect  pests  is,  of  course, 
mainly  from  flies  and  mosquitoes  (Fig.  77  and  78).  The  inade- 
quate methods  of  disposing  of  human  wastes  afford  opportunity  for 
typhoid  transmission;  the  relatively  small  number  of  people  make 
malaria  transmission  quite  frequent,  if  malarial  persons  are  also 
residents  of  that  same  area.    The  longer  periods  spent  in  the  open. 


252 


HOME  AND  COMMUNITY  HYGIENE 


and  the  difficult}'  in  completely  screening  tents  add  greatly  to  the 
opportunities  for  disease  transfer  (see  Appendix). 

BUZZ!  BUZZ!  BUZZ! 


THE  FLY  THAT  UVES 
TO  FLY  AWAY 

WILL  LIVE  TO  BREED 
A  MILLION  A  DAY. 


NLL^NOW 


Fig.  77. — The  fly  menace. 


General  Warning. — All  the  cleanly  and  preventive  measures 
desirable  at  home  must  be  emphasized  here,  for  there  is  a  great 
tendency  to  "  let  down "  on  all  the  sanitary  customs,  trusting 
"  country  air  "  or  some  other  influence  equally  vague. 


SUMMER  CAMPS 


253 


FLIES  &  MOSQUITOES 

Are  your  dangerous  enemies 

They  breed  in  filth 

They  carry  disease  and  death 

Remember  their  names  and 

what  they  stand  for! 

FROM 


Typhoid  Fly 

(The  Common  Fly) 


Manure  piles 
^  Cesspools 

Filthy  stables 

^  Offal 
Dead  carcasses 


Malarial^ 
Mosquito^  ^ 

(ihe  ordinary  mosfluit^ 

Stagnant  water 

Slops 

Dirty  troughs 

Privies 

Spittoons 


TO 

Mourfood  ^ 
Your  drink  ^ 
Your  lips 


Kill  flies  and  mosquitoes 

Destroy 

their  breeding  places 

Cover  up  your  food 

Starve  the  fly! 


Tfcparcd  by  Dr.  Tho; 


,i>  D  WwxJ,  515  Wc 
,  YuHi  Oty.     1918 


Clean  stables 

Clean  privies 

Every  home  and  school 

should  be  screened 

Shut  out  the  fly! 


dnoorii  by  courtesy  of  Emeit  H^mlin  Baker. 


Fig.  78. — Lessons  for  the  housekeeper  and  camper. 


254  HOME  AND  COMMUNITY  HYGIENE 

PROBLEMS 

1.  Make  a  set  of  health  rules  for  a  camp  of  girls  14  to  17  years  old; 
for  boys  10  to  14  years  old. 

2.  What  three  fundamental  healtii  or  sanitation  standards  would  you 
demand  for  a  camp  of  berry  pickers  who  are  housed  and  fed  on  the  fruit 
farm? 

1       3.  What  are  the  sanitary  requirements  you  would  have   in  mind  in 
buying  ground  for  a  permanent  summer  camp? 

4.  What  are  the  sanitary  provisions  one  should  make  in  planning  a 
canoe  trip  down  a  river? 

5.  One  American  city  conducts  a  municipal  camp  open  successively  to 
various  groups  of  people :  young  working  women,  family  groups,  and  young 
men.  If  you  were  responsible  for  the  sanitary  policy  what  points  would 
you  emphasize  for  all  three  groups?  What  differencesi  might  be  advisable 
or  safe? 

6.  What  is  the  best  method  of  disposing  of  garbage  in  summer  camps 
(see  Chapter  VIII)  ? 

7.  Write  a  short  article  on  drinking  water  (standards,  dangers,  and 
treatment)  that  your  local  paper  could  use  to  influence  people  in  making 
their  variation  plans. 

8.  Support  the  statements  and  implications  in  Fig.  78  by  definite  facts. 

See  Reference  List  at  end  of  Appendix. 


CHAPTER  XV 

SCHOOLS 

While  most  of  the  material  presented  in  this  chapter  is  ap- 
plicable to  large  school  buildings  as  well  as  small  houses,  no  attempt 
is  made  to  include  such  topics  as  the  complicated  systems  of  heat- 
ing and  ventilation  found  in  large  schools  only.  The  chapter  on  the 
home  includes  an  elementary  discussion  of  heating,  lighting,  and 
ventilation  that  should  be  read  by  teachers;  more  on  these  and  re- 
lated topics  is  to  be  found  in  the  chapters  on  air  and  ventilation, 
sewage  disposal  and  infant  welfare ;  the  chapters  on  transfer  of  dis- 
ease and  disinfection  and  quarantine  should  be  read  by  all  teachers, 
and  those  who  do  not  realize  that  "  the  whole  child  goes  to  school " 
should  include  the  functions  of  food  in  the  body.  Most  helpful, 
also,  even  to  city  teachers,  are  the  pamphlets  on  Minimum  Health 
Eequirements  for  Eural  Schools  and  on  Minimum  Health  Essen- 
tials for  Eural  School  Children,  listed  in  the  Appendix. 

Health  Responsibilities  of  Teachers. — The  day  is  past  when 
even  a  poor  teacher  feels  she  has  discharged  her  full  duty  when  she 
has  attended  to  the  mental  development  of  her  charges.  But  while 
every  teacher  recognizes  the  need  of  preventing  the  transfer  of  such 
serious  diseases  as  diphtheria,  there  is  too  often  a  lack  of  compre- 
hension of  the  real  nature  of  such  insidious  diseases  as  tuberculosis, 
of  the  attending  evils  of  such  common  disease  as  colds,  sore  throats, 
and  "  grip,"  and  in  some  localities  a  disgraceful  apathy  to  such 
local  diseases  as  malaria  and  hookworm. 

Prevention  of  Disease  by  Special  Treatment. — In  such  cir- 
cumstances, compulsory  education  may  mean  compulsory  contrac- 
tion of  disease.  Scientific  precautions  should  be  taken  to  prevent 
such  transfer  of  disease.  Smallpox  should  be  prevented  by  vac- 
cination— ^before  the  little  child  first  enters  school  and  again  be- 
fore high  school  is  begun.  The  prevention  of  diphtheria  is  now 
possible  by  the  injection  of  the  modified  toxin  recently  advocated, 
though  antitoxin  is  still  used  in  such  emergencies  as  epidemics 
(p.  206). 

255 


256  HOME  AND  COMMUNITY  HYGIENE 

Epidemics. — Epidemics,  sucli  as  diphtlieria  and  measles,  may 
be  prevented  by  prompt  exclusion  of  the  affected,  or  by  closing  the 
schools  for  the  usual  incubation  period  of  the  disease.  By  that  time 
those  who  have  contracted  the  disease  from  first  cases  can  be  de- 
tected, and  the  well  can  be  allowed  to  return  to  school.  See  chart 
(Fig.  49)  opposite  page  186  for  rules  concerning  exclusion  from 
school.  If  the  epidemic  spreads  despite  the  closing  of  the  schools, 
the  spread  is  due  to  some  other  factor,  such  as  milk  or  healthy 
carriers ;  this  cause  should  be  determined  and  eliminated.  It  is,  of 
course,  of  little  use  to  close  the  school,  if  the  children  are  still  inti- 
mately associated  in  playground,  Sunday  school,  or  settlement 
classes  (see  p.  184). 

Carriers. — In  diseases  often  spread  by  healthy  carriers,  such  as 
diphtheria,  or  where  the  beginning  symptoms  are  pronounced,  as  in 
measles,  it  is  often  better  to  continue  the  schools,  examining  the 
children  as  they  appear  on  the  school  grounds  (not  allowing  close 
contact)  and  excluding  all  suspects.  In  diphtheria,  microscopic 
examination  of  the  throats,  especially  the  throats  of  those  in  close 
contact  with  the  early  cases,  will  enable  the  inspector  to  eliminate 
those  who  are  carriers,  as  well  as  those  coming  down  with  the  dis- 
ease (p.  213). 

Hygienic  Relations  of  Equipment. — The  school  control  of 
such  diseases  as  common  colds  and  grip,  which  are  not  always  con- 
sidered sufficient  cause  for  exclusion,  etc.,  is  more  difficult.  In 
this  connection  the  teacher  should  study  carefully  the  tables  on 
transfer  of  disease  (pp.  173,  174  and  the  chart  opposite  p.  186). 
School  equipment,  such  as  drinking  cups,  may  convey  infection. 
Wherever  possible  the  equipment  should  be  individual,  e.g.,  pencils, 
books,  and  towels.  Articles  necessarily  used  in  common  should  be  of 
the  type  least  likely  to  convey  infection  (smooth  surfaces,  washable, 
etc.).  Water  closets  or  privies  should  be  so  constructed  that  splash- 
ing does  not  occur,  the  seats  should  be  U-shaped,  so  that  unneces- 
sary contact  of  sensitive  surfaces  is  avoided.  Basins,  etc.,  should 
be  kept  clean.  While  surfaces  which  seem  clean  may  carry  in- 
fectious organisms,  surfaces  which  are  visually  soiled  or  sticky  are 
most  likely  to  do  so.  Hands  are  preferably  washed  under  running 
water,  not  in  a  soiled  basin.  Drinking  fountains  should  be  sub- 
stituted for  common  drinking  cups,  unless  it  is  possible  to  have 
individual  cups  and  make  sure  their  use  is  limited  to  the  individual 


SCHOOLS 


257 


owner.  Some  drinking  fountains  are  as  bad  as  the  common  drink- 
ing cup.  Even  good  types  are  dangerous,  unless  a  good  flow  of  water 
is  assured,  sufficient  to  wash  off  the  deposits  left  by  the  last  drinker. 
Drinking  fountains  on  the  upper  floors  where  the  flow  is  very  low 
may  retain  organisms  for  hours.  The  best  types  are,  therefore, 
those  which  do  not  allow  the  mouth  to  touch  the  metal  and  which 
do  not  allow  water  once  in  contact  with  the  mouth  to  settle  back  on 
the  fountain  (Fig.  79).    In  fountains  having  a  vertical  instead  of 


'■^^;. 


Fig.  79. — Water  fountain  in  which  one  drinks  from  the  curve  of  the  water  current;  spreading 
prongs  near  the  top  of  the  outer  tube  prevent  mouth  contact  with  either  tube. 

an  oblique  flow,  it  is  claimed  that  bacteria  may  be  kept  rising  and 
falling  in  the  jet  of  water,  just  as  a  ball  is  sometimes  kept  playing  in 
the  ornamental  fountains  of  gardens  and  lawns. 

There  are  many  other  factors  or  situations  that  interfere  directly 
with  the  mental  progress  of  the  pupil  and  which  predispose  to 
disease.  These  situations  or  conditions  include  such  widely  varying 
factors  as  inadequate  lighting,  heating,  and  ventilation,  incorrect 
posture,  and  definite  physical  defects,  such  as  adenoids.  We  will 
discuss  first  important  points  concerning  the  building  and  its  equip- 
17 


258  HOME  AND  COMMUNITY  HYGIENE 

ment,  and  then  the  physical  defects  of  the  pupils  which  should  be 
corrected,  or  at  least  considered  in  the  educational  scheme. 

Location  and  Grounds. — The  building  should  be  easily  acces- 
sible to  most  of  the  children  attending,  unless  a  school  conveyance 
is  provided  for  children  who  would  otherwise  have  to  walk  too  far. 
Conveyance  for  the  winter  months  or  stormy  days  could  be  pro- 
vided in  many  localities  at  small  cost,  as  such  conditions  often 
interfere  with  the  use  of  horses  on  farms,  etc. 

The  question  of  ornamental  grounds  versus  playgrounds  often 
has  to  be  decided.  In  some  localities  it  is  wrong  to  take  space  for 
ornamental  planting  that  ought  to  be  given  to  playground  space. 
A  minimum  of  thirty  square  feet  for  each  child  is  strongly  recom- 
mended. If  the  area  available  is  much  less,  ornamental  planting 
should  be  planned  to  get  the  most  effective  results  with  a  minimum 
area  (borders,  corners,  etc.) ;  the  recess  and  even  the  beginning  and 
closing  hours  should  be  adjusted  to  meet  such  space  handicaps. 

The  building  should  be  in  as  quiet  a  place  as  the  distribution  of 
the  pupils  will  allow.  Too  often  schools. are  thoughtlessly  placed  on 
any  undesirable  strip  of  ground,  and  the  pupils  are  sometimes  con- 
stantly subjected  to  objectionable  smoke  or  gases  or  to  interminable 
noises.  The  effect  upon  the  nerves  can  be  seen  in  the  tense  expres- 
sion of  teacher  and  pupils  and  in  the  irritated  frown  that  involun- 
tarily accompanies  marked  or  sudden  increases  in  outside  noise. 
The  effect  upon  the  speaking  voice  is  most  unfortunate.  The 
school  should  be  a  place  of  quiet,  for  there  is  no  reason  for  think- 
ing that  only  adults  can  work  better  in  a  quiet  atmosphere.  Such 
objectionable  environments  often  make  it  necessary  to  keep  the 
windows  closed,  and  interfere  with  the  proper  ventilation  of  the 
schoolroom. 

Lighting. — Ordinarily  the  window  space  should  be  one-sixth 
to  one-quarter  the  floor  space.  In  long  rooms  with  windows  at  the 
end  only,  this  must  be  decidedly  increased.  The  proximity  of  other 
buildings  would  make  similar  increases  necessary.  Lighting  must 
be  judged  by  the  amount  available  in  the  poorest  seat  in  the  room 
on  cloudy  or  dull  days.  If  the  windows  are  high,  the  light  pene- 
trates farther  into  the  room,  for  one-third  of  the  light  enters 
through  the  upper  fourth  of  the  window.  Shades,  therefore,  should 
be  fastened  in  the  middle  or  at  the  bottom  to  enable  the  teacher  to 
modify  the  light  without  unduly  darkening  the  darker  parts  of  the 


SCHOOLS  259 

room.  The  shades  and  walls  should  be  of  some  soft,  dull  color,  the 
shades  preferably  greenish  and  quite  opaque.  The  light  should 
come  from  the  back  or  the  sides  of  the  room,  preferably  from  the 
left  side. 

Heating. — Small  schools  are  usually  heated  by  stoves  placed  in 
the  room.  (See  the  chapter  on  The  Home  for  types  of  heating 
and  ventilation. )  The  thermometer  should  be  kept  at  the  "  breath- 
ing line,"  and  should  never  exceed  20°  C.  (68°  F.) ;  lower  tempera- 
ture is  considered  advisable  by  many  (see  Temperature,  Chapter 
VI).  The  even  distribution  of  heat  throughout  the  room  is  much 
more  important  in  schools  than  in  a  house  where  greater  freedom 
of  movement  is  possible. 

The  jacketed  stove  (Fig.  80)  is  advocated  for  rooms  where 
children  sit  in  fixed  seats  at  varying  distances  from  the  source  of 
heat.  Sufficient  oxygen  for  fuel  combustion  and  a  safe  margin 
for  the  occupants  is  insured  by  a  definite  air  intake,  which  is  really 
very  easy  to  construct.  A  little  opening  in  the  side  wall  can  have 
a  small  pipe  inserted  in  winter  time  opening  directly  into  the  room 
above  the  floor.  This  can  be  closed  by  a  grated  or  shutter-like 
"register"  when  not  in  use.  In  the  illustration  the  intake  pipe 
opens  directly  under  the  stove. 

The  jacketed-stove  system  must  have  the  used  air  removed  from 
the  bottom  of  the  room,  thus  drawing  the  warm  air  down  to  the 
colder  floor  levels.  For  this,  an  opening  into  the  stovepipe  is 
necessary,  connecting  the  used  floor  air  of  the  room  (outside  the 
screen)  with  the  stovepipe;  the  upward  rush  in  the  stovepipe 
carries  the  used  room  air  with  it.  Two  improvements  might  be 
made  to  the  usual  arrangement:  (1)  Placing  the  stove  some  dis- 
tance out  into  the  room  so  that  the  opening  for  used  air  will  be 
farther  from  the  stove  and  so  insure  a  more  complete  mixing  of  the 
warmed  air  with  the  general  room  air.  (3)  The  second  is  using  a 
screen  to  deflect  some  of  the  heated  air  down  to  the  colder  floor 
level  where  we  really  live,  and  toward  parts  of  the  room  not  so 
directly  in  the  warm  descending  current.  Such  a  shield  would  be 
unsightly,  and  give  an  added  area  for  dust  collection.  But  on 
these  points  little  can  be  said  in  favor  of  stoves  and  stovepipes  gen- 
erally. Additional  window  ventilation  does  not  interfere  with  this 
method  of  heating  and  ventilating. 

Inadequate  ventilation  is  a  common  fault  of  the  schoolroom. 


260 


HOME  AND  COMMUNITY  HYGIENE 


Each  child  should  have  2000  cubic  feet  of  fresh  air  hourly;  to 
avoid  too  great  drafts  in  the  displacing  of  the  used  air,  a  minimum 
room  space  of  240  cubic  feet  is  recommended.  If  inlets  and  out- 
lets are  on  the  same  side  of  the  room  a  better  mixture  of  the  air  is 


Fig.  80. — .Jacketed  stove;  the  fresh  air  inlet  may  be  cut  through  the  wall  directly. 
A  floor  inlet  is  better  when  the  stove  is  some  distance  from  the  outside  wall.  Notice  that  the 
outlet  for  used  air  connects  with  the  stovepipe;  this  helps  draw  out  the  used  air. 


effected,  especially  if  the  heated  air  is  admitted  at  least  seven  feet 
above  the  floor  and  the  used  air  is  taken  out  at  the  floor  level 
(Fig.  34).  These  openings  should  be  adequate,  about  sixteen  to 
twenty  square  inches  for  each  child  (if  no  special  pumping  or 
exhaust  S3'stem  is  used). 

Window  Ventilation. — "Window  ventilation  is  valuable,  if  the 


SCHOOLS  261 

teacher  can  be  trusted  to  attend  to  it  properly.  Special  ventilators 
can  be  placed  in  the  windows  to  shut  off  drafts.  Where  radiators 
are  used,  the  radiator  can  be  placed  under  the  window  to  insure  the 
heating  of  the  entering  air,  thus  avoiding  a  chill.  Usually,  window 
ventilation  may  be  combined  with  the  heating  or  ventilating  sys- 
tem employed,  and  periodical  flushing  of  the  room  with  fresh  out- 
door air  by  wide-open  windows  is  most  desirable.  Schoolrooms 
should  be  aired  in  the  unused  periods,  yet  usually  the  last  thing 
the  teacher  does  on  leaving  the  room  for  the  night  is  to  close  the 
windows.  Storms  must  be  considered,  but  a  little  planning  would 
make  it  possible  to  air  schoolrooms  over  night  and  over  week  ends 
without  too  much  danger  from  rains,  cold  snaps,  etc. 

Recently  a  study  was  made  in  New  York  City  of  over  5000 
children  eight  to  eleven  years  old,  representing  three  different  types 
of  ventilation:  (a)  ventilation  by  open  windows,  room  temperature 
ranging  from  10°  to  16°  C.  (50°  to  60°  F.) ;  (b)  window  ventila- 
tion (often  with  deflectors  to  avoid  drafts),  with  temperature  rang- 
ing from  16°  to  21°  C.  (60°  to  70°  F.)  averaging  20°  C.  (68° 
F)  ;  and  (c)  mechanically  ventilated  rooms  with  closed  windows, 
the  temperature  averaging  17°  C.  (63°  F.)  here  also.  The  results, 
judged  (1)  by  the  absences  due  to  respiratory  diseases,  and  (2)  by 
the  number  of  those  attending  though  suffering  from  respiratory 
diseases  (colds,  etc.),  for  the  flfty  to  seventy-day  periods  studied 
were  in  favor  of  the  open-window  ventilation.  In  the  open-window 
room  with  the  higher  temperature  the  respiratory  disease  absences 
were  32  per  cent,  higher  than  in  the  open-window  low  temperature 
room;  in  the  mechanically  ventilated  room  they  were  40  per  cent, 
higher  than  in  the  open-window  low  temperature  room. 

The  respiratory  diseases  occurring  in  those  not  too  ill  to  attend 
school  were  found  to  be  70  per  cent,  higher  in  the  open-window 
low  temperature  room  than  in  the  warmer  open-window  room. 
But  in  the  closed- window  room  they  were  higher  still,  98  per  cent, 
higher.  This,  as  is  evident,  is  a  strong  argument  for  window  venti- 
lation, but  for  window  ventilation  without  constant  drafts. 

Open-air  Schools. — It  must  be  remembered  that  the  respira- 
tory diseases  which  allowed  the  children  to  remain  in  attendance 
were  not  serious  ones.  There  is,  however,  a  general  impression 
among  teachers  that  outdoor  and  open-window  schools  are  more 
favorable  to  general  health  than  the  above  implies.    The  results  of 


262 


HOME  AND  COMMUNITY  HYGIENE 


Open  Window  Rooms  for 
Every  School  Child 

Much  of  the  poor  health  and  dulhiess 
of  school  children  is  due  to  the  foul 
air  in  badly  ventilated  school  rooms 


Draft  screens  practical  for  tlie.open  windows 
in  an\'  scliool  room 


1 

1 

■^r 

11      Ijj  .    Ilj 

i;  m 

i 

^^-rr<**"  ' 

^  \'^^iit^  < 

^A- 

p^-^ 

:^^          VK^ 

A  thin  muslin  screen  lets  in  the  out-door  air 
but  cuts  oil"  drafts.  Easil\- 
fitted  toan\'0[ien  window 


Open  windows  still  tlie  surest  way  to 
\  entilnce  a  school  room 


Counoy  of  Eli/Jbclh  McCormick  Memorial  Fund 
^  I  5  Plymouth  Couit,  Chicago,  Illinois 


Commiitot  on  I  It-.ilth  I'robkms  of  X.uion.il  Council  of  Kdu 
.md  Anicircan  Mtdicjl  A~n.eijtion 


Fig.  81. — Notice  the  types  of  screens  in  these  fresh-air  schoolrooms. 


SCHOOLS  263 

physical  examinations  of  children  during  the  school  year  justify 
the  establishment  of  open-air  schools  or  open-window  classes,  if 
proper  clothing  can  be  provided  (Fig.  81). 

Cloakrooms. — CloaJsrooms  and  toilet  rooms  should  be  well 
ventilated.  Many  teachers  prefer  to  have  the  cloakrooms  entered 
only  from  the  schoolroom,  thus  assuring  full  control ;  in  such  cases 
care  must  be  taken  to  see  that  the  ventilation  scheme  carries 
the  cloakroom  air  out  through  separate  openings — not  into  the 
schoolroom. 

Cleaning. — The  equipment  should  have  surfaces  that  are  easily 
cleaned  and  kept  free  from  dust.  Yacuum  cleaning  is  preferable 
to  sweeping  and  dusting;  where  they  are  employed  dust  should  be 
avoided  by  dusting  with  moist  or  oiled  dusters,  and  sweeping  with 
moistened  brushes  or  using  wet  sawdust  or  paper.  (There  is  no  ex- 
cuse, of  course,  for  re-using  soiled  sawdust.)  Windows  admit 
more  light  if  clean.    Dustless  crayons  should  be  used. 

Seating. — The  desks  and  chairs  should  be  adapted  to  the  child. 
Grooved  or  hollowed  seats  tend  to  lessen  sliding  forward  in  the  seat 
and  sitting  too  far  up  on  the  spine.  The  seats  should  vary  in  size 
in  any  given  room;  and  these  seats  should  be  adjusted  or  changed 
at  least  twice  a  year  to  suit  the  growing  child.  The  slant  and 
relative  height  of  the  desk  should  provide  the  least  eye  strain  and 
avoid  undue  bending  or  "  hunching  "  of  the  shoulders.  Usually  the 
desk  is  best  placed  at  one  inch  ahead  of  the  front  edge  of  the  seat, 
and  at  a  level  with  the  elbows. 

Personal  Cleanliness. — In  some  localities  shower  baths  should 
be  provided  for  children  not  properly  provided  for  at  home.  Warm 
water  should  be  available  for  hand  washing  at  least  in  the  winter 
time.  Tooth  brush  drills  seem  to  be  helpful.  And  attention  should 
be  given  to  inculcating  clean  personal  habits,  especially  care  of  the 
nose,  spitting,  and  keeping  fingers  in  the  mouth  and  nose  (Fig.  83). 
Home  habits  are  often  most  undesirable  in  these  respects ;  we  must 
also  remember  that  "  cleanliness  is  not  instinctive  and  must  be 
learned"  (seep.  170). 

Fatigue. — Even  with  the  best  equipment  possible,  children  may 
be  unduly  fatigued  by  the  school  day.  Excitability  is  one  early 
symptom  of  fatigue,  and  teachers  must  not  be  misled  by  it.  Fatigue 
due  to  overheated  or  poorly  ventilated  rooms  is  not  to  be  excused. 
The  relative  length  of  the  periods  given  to  play  and  work,  to  stand- 


264 


HOME  AND  COMMUNITY  HYGIENE 


Avoid  Spreading  Disease 
At  School  and  at  Home 


A  pencil  pasj^ed  from  mouth  to  mouth  cirries 
\\ith  it  disease  trerms 


r>angerous   dise-a.se.s  arc 

caught  b\' drinking  from 

a  lup  used  hv  otiiers 


Your  hands  airr\"  disease 

germs.   Wash  them  al- 

\\a\'S  before  eating.   l.'se 

an  indi\"idual  towel 


The  eonimon  towel  sjireads 

e\"e  and  skin  diseases.  It  i,-; 

a  menace  to  hralth 


. ;  \\\-.t  iicihSim 


Lon  Ili.llch  Pinhlcnlsr.l'N".ili..njl  (.:niiiicil  orKdli 
•Jiul  Ar)Rn>;jn  Mcdicjl  As,o.,-ijrion 


Fig.  82. — Do  you  know  any  children  who  are  not  careful  about  these  things? 


SCHOOLS  265 

ing  and  sitting  exercises,  is  important  in  relation  to  fatigue,  and  in 
creating  bad  postures.  A  tired  child  neither  stands  nor  sits  well; 
this  leads  to  defects  which  are  far  reaching  in  their  physical  effects ; 
for  example,  a  stooping  sitting  posture  may  cause  eye  defects,  spinal 
curvature,  or  a  cramped  lung  area  and  an  overworked  heart.  Bad 
sitting  positions  do  more  harm  than  bad  standing  positions,  be- 
cause one  sits  more  hours  than  one  stands.  Parents  and  teachers 
pay  less  attention  to  the  sitting  positions,  however,  because  they 
attract  less  attention. 

Food. — Proper  feeding  (warm  midday  lunches,  a  recess  sand- 
wich) may  do  much  to  lessen  the  fatigue  of  school  life.  Where  mal- 
nutrition exists,  this  should  be  met  by  free  or  low-priced  lunches, 
preferably  warm  ones.  A  census  of  fifteen  cities  in  1913  covering 
over  500,000  children  indicated  that  at  least  5  per  cent,  were  under- 
nourished. ISTew  York  City's  rate  was  4  per  cent. ;  Providence  con- 
tained 11  per  cent.,  and  Louisville  but  %  per  cent.  New  York  City 
tries  to  provide  400  to  500  calories  (G)  for  three  cents. 

Physical  Defects. — The  extent  of  the  physical  defects  common 
in  school  children  is  indicated  by  Fig.  105.  Other  investigators  re- 
port for  large  numbers  of  children  still  higher  percentages  of 
defects ;  for  example,  15  per  cent,  ear  defects,  30  per  cent,  eye  de- 
fects, and  24  per  cent,  enlarged  glands. 

The  percentage  of  men  rejected  for  defective  teeth  and  eyes  in 
the  recent  war  indicates  that  these  defects  remain  uncorrected  in 
great  part.  It  is  surprising  how  long  eye  defects  remain  unsus- 
pected.^ The  effect  of  adenoids  (Fig.  83)  upon  health  and  mental 
development  as  well  as  hearing  is  most  remarkable  (Chapter  XXI). 
They  cause  not  only  slowing  of  mental  processes,  but  often  lead  to 
truancy,  incorrigibility  and  actually  immoral  actions.  One 
investigation  showed  that  90  per  cent,  of  the  backward  and  un- 
successful had  physical  defects;  40  per  cent,  of  these  included 
marked  enlargements  of  tonsils  and  adenoids.  Too  often  the  de- 
fects are  not  attended  to ;   careless  procrastination  is  the  usual 

^  One  little  girl  of  seven  who  had  labored  under  an  unsuspected  eye 
handicap  for  two  years  was  finally  examined  for  glasses.  When  the  oculist 
fitted  in  the  correct  trial  lenses,  and  the  blurred  letters  became  clear,  she 
asked  in  surprise,  "Do  the  letters  look  like  that  to  everybody?"  On  being 
told  that  they  did,  she  burst  into  tears  in  sheer  excitement  over  thinking 
that  now  she,  too,  could  tell  the  letters  apart  and  wouldn't  be  stupid  any 
more. 


266 


HOME  AND  COMMUNITY  HYGIENE 


Adenoids  and  Enlarged  Tonsils 
Make  Backward  Pupils 

Aj:)pcamiK'c  of  a  itiild  with  nvarkcil 
•.uii-iK)iil  fnlar<iL'mcnt,  nioudi  (jpcn; 
dull,  ^l(.■l■p^',  with  inciuirinL;  lo'il.; 
ujipcr  lij)  sliort  and  tliick;  ui^pcr  jaw 
narr<i\\:  naN-.il  oritiiH's  small  and 
pinclu-tl,  tilt-  t'.K't'  lull  under  tin-  c\  t-s; 
listless  and  indisposeti  to  pliVsieal  oi- 
mental  e.\erti(jn;stupitland  back  wai'd; 
inM-lioul.tromonetotw  o\  earsbehind 
the  normal  ot'saiiie  aL'e;  undersized 


l'"aee  deformed  by 
mouth  breathing 

MoLirh  brcachini^  is  inju- 
rious to  development 
and  health 


'J'he  s-.inie  child 
after  treatment 


.\denoids  foree  a  child  to 

breathe  til  roiij^h  the  mouth 

instead  of  the  nose 


Adenoids  Often  Result  in. 


Obstrueted  bre-athini^ 

(lironic-  nasal  catarrh 

Detects  in  sense  ot' smell  and  taste 

Malnutrition  and  ani'mia 


Mental  disturbanees. 
IJeatiies>  mid  e;iraehr 
Deti'Cts  in  ^  oiie    nas.il  \  .liee 
I'lnsit~il  anil  mental  underde\  eloimient 


Tonsils  Make  a  (>lii]d  an  Easy  Vietim  of 


Tonsillitis 
(.)uins\'  • 


Diphtheria 
Rheumatism 


Tuberculosis 
Pneumonia 


l'r((.jK.I  I.;    I)t.    f! 


i:„„iiiili.t  .Ml  Hcnith  rH.l.kni-  ..r\j... .11,11  C.i.ncil  ..ri'idu 
jiid  AiiKiiL.M.  MtJicjl  A.M.,.ulion 


FiQ.  83. — Do  you  know  a  mother  or  father  who  should  see  this  chart? 


SCHOOIS 


267 


Health  Examinations  Made 

Effective  by  Follow-up  Service  of 
School  Nurses 


Per  Cent 


Recommendali  ons 
Doctors  /Icted  Upon 

TREATMENT 
OBTAINED  FOR.: 

Teeth 


Eyes 


Adenoids 


Tonsils 


Percent  lo        so       30        10        so        «o        10        so         so      100 


Results  with  Nurses' Aid 


Results  Without  Nursesf  Aid 


Results  of  Health  Examinations  with  and  without 
Nurses' Follow-up  Aid 

Percentages  Based  on  Two  Groups  of  1,353  and  1,780  Children  in 
Philadelphia  Schools  Found  with  Physical  Defects 


Dr.  Ncwmayer's  Repon 


I  Health  Problems  of  National  Council  of  Education 
and  American  Medical  Association 


Prepared  by  Dr  Thomas  D.  Wood,  515  West  120th  Street 
New  York  City.     1918 


Fig.  84. — A  strong  argument  for  having  school  nurses. 


268 


HOME  AND  COMMUNITY  HYGIENE 


reason,  but  often  lack  of  money  is  the  real  reason.  There  are  for- 
tunately but  few  parents  who,  for  sheer  stubbornness  or  because 
of  "  the  looks/'  refuse  to  provide  glasses  or  other  needed  aids. 

School  Inspection. — While  the  regular  teacher  can  detect  many 
of  the  defects  which  interfere  with  a  pupil's  development,  the  ser- 
vices of  a  nurse  are  most  valuable  in  emergency  work,  in  diagnos- 
ing incipient  disease,  and  still  more,  perhaps,  for  "  follow-up " 
work  in  the  home  (Fig.  84).  The  services  of  more  specifically 
trained  people  will  be  needed,  however,  for  many  conditions;  e.g., 
the  type  of  eye  defects,  or  nervous  affection,  or  to  decide  authori- 
tatively concerning  operations  for  adenoids,  etc.  It  has  been  shown 
that  75  to  90  per  cent,  of  the  defects  are  corrected  when  a  school 
nurse  or  physician  is  employed,  and  but  15  to  25  per  cent,  where 
there  is  no  trained  nurse  or  adviser.  Some  schools  have  a  rapid 
daily  inspection  by  doctor,  nurse  or  teacher  to  eliminate  com- 
municable diseases. 

Each  child  should  have  a  medical  examination  at  least  once  a 
year,  but  twice  a  year  is  desirable :  one  in  the  fall  to  determine  gen- 
eral fitness  for  school  work,  necessary  corrective  work  (exercises, 
glasses,  etc.) ;  a  second  one  in  late  spring  or  early  summer  may 
help  determine  the  summer  vacation  plans.  Eeports  should  be 
filled  out  showing  definitely  the  condition  of  the  child,  and  the 
corrections  most  desirable  (Fig.  85).  Parents  take  more  in- 
terest in  such  examinations,  if  they  are  invited  to  be  present;  and 
the  examination  can  be  more  thorough  (less  clothing),  if  the  par- 
ents are  present.     The  following  is  a  simple  card  which  even  a 


September 
Examination 


Spring 
Examination 


Average 


Weight 

Height 

Girth  of  chest 

Girth  of  chest  expanded. 

Lung  capacity 

Strength,  R.  forearm  .  .  . 
Strength,  L.  forearm  .  .  . 


lbs. 
in. 
in. 
in. 
cu.  in. 
lbs. 
lbs. 


These  averages  are  those  for  a  person  of  your  age  and  your  height.    The 
average  height  for  a  hoy  {girl)  of  your  age  is 


>  tz;  1-5  »  n 


?a  H  > 


•8     3 


s' !?  g; 


3!    S^ 


SCHOOLS 


ffi  r  m    ?^  w  m 
t    d    »     s-   ™    » 


^  ?  "   S,  2,  S    §    § 
3    ^   «.         5:   a-_   -■   "• 

"■  c^  ?■  j;  ? 


1^ 

3' 


—    m     C 

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►<:'o  2 


I  °  s 


269 


z  o 

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3     n 


JO  O  O  K 

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a    (D    111    5" 


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270  HOME  AND  COMMUNITY  HYGIENE 

child  can  understand,  and  which  shows  general  defects  very  clearly. 
A  more  detailed  one  is  advisable  for  the  school  records  (Fig.  85). 

The  first  city  to  begin  medical  school  inspection  was  Boston,  in 
1894.  Now  there  are  at  least  eighty  cities  with  medical  inspections, 
though  some  of  these  do  not  really  deserve  to  be  classed  in  this  list ; 
for  instance,  one  has  medical  inspection  every  three  years !  Some 
of  them  provide  free  clinics  for  diagnosis  and  a  few  of  them  clinics 
for  treatment.  Of  100  cities,  77  reported  one  or  more  clinics;  only 
22  of  these  cities  had  school  clinics,  the  other  clinics  being  sup- 
ported by  hospitals  or  other  organizations.  Dental  clinics  were  the 
most  common,  59 ;  next  eye  clinics,  28,  and  ear,  20,  with  psychologi- 
cal and  general  clinics  numbering  16  and  14  respectively.  Nose 
and  throat  clinics  number  but  8 ;  orthopgedic,  4 ;  tuberculosis,  3 ;  and 
24  unclassified  clinics  bring  the  total  for  the  77  cities  to  but  176 — 
not  three  apiece ! 

School  Nurses. — Nurses  are  provided  somewhat  more  gener- 
ously. In  1916  one  hundred  of  121  cities  reported  school  nurses. 
Some  of  these  averaged  but  one  nurse  for  from  3000  up  to  8000 
children.  This  proportion  is  most  unwieldy,  and  diminishes  greatly 
the  efficiency  of  the  work,  and  may  so  discredit  it  that  it  is  a  distinct 
setback  to  the  whole  movement.  See  the  chapter  on  rural  and  city 
conditions  (p.  351)  for  other  phases,  of  this  problem  of  defects  in 
school  children. 

Additional  Considerations. — School  inspection  should  include 
also  an  inspection  of  the  school  buildings,  including  such  phases  as 
the  toilets,  water  supply,  methods  of  cleaning,  ventilating,  and 
heating  (Fig.  115). 

An  inspection  of  the  teachers  is  also  desirable;  it  would  make 
possible  the  provision  for  leave  of  absence  for  needed  rest  or  treat- 
ment, and  the  elimination  of  over-nervous  teachers  who  continue 
to  hold  their  positions  because  of  pension  or  tenure-of -office  rulings. 

The  intelligent  really  need  no  arguments  for  school  inspection. 
It  is  the  ignorant  and  the  selfish  taxpayers  who  need  a  health  cam- 
paign to  convince  them  that  "it  is  folly  to  spend  money  on  the 
education  of  children  who  are  prevented  by  disease  from  becoming 
educated." 


SCHOOLS 


271 


Ten  Golden  Rules  of  Health 
for  School  Children 


1.  Play  hard  and  fair— be  loyal  to 
your  team-mates  and  generous  to 
your  opponents 

2.  Eat  slowly.  Do  not  eat  between 
meals.  Chew  food  thoroughly.  Never 
drink  water  when  there  is  food  in  the 
mouth.  Drink  water  several  times 
during  the  day 

3.  Brush  your  teeth  at  least  once 
a  day.  Rinse  your  mouth  out  well 
with  water  after  each  meal 

4*  Be  sure  your  bowels  move  at 
least  once  each  day 

5*  Keep  clean— body,  clothes  and 
mind.  Wash  your  hands  always  before 
eating.  Take  a  warm  bath  with  soap 
once  or  twice  a  week;  a  cool  sponge 


(orshower)bath  each  morning  before 
breakfast  and  rub  your  body  to  aglow 
with  a  rough  towel 

6.  Try  to  keep  your  companions, 
especially  young  children,  away  from 
those  who  have  contagious  diseases 

^.  Use  your  handkerchief  to  cover 
a  sneeze  or  cough  and  try  to  avoid 
coughing,  sneezing,  or  blowing  your 
nose  in  front  of  others 

O.  Study  hard— and  in  study,  work 
or  play  do  your  best 

9.  Sleep:  Get  as  many  hours  in  bed 
each  night  as  this  table  indicates  for 
your  age.  Keep  windows  in  bedroom 
well  open 


HOURS  OF  SLEEP  FOR  DIFFERENT  AGES 

Age  Hours  of  Sleep 

5  to  6  13 

6  to  8  12 

ii'A 


o  to  10 

10  to  12 
12  to  14 

14  to  16 
16  to  18 


II 

lo'A 

10 

91 


10.  Be  cheerful,  and  do  your  best  to  keep  your  school  and  your  home  clean 
and  attractive,  and  to  make  the  world  a  better  place  to  live  in 


Prtparcd  by  Dr  Thoi 


i  D.  Wood,  515  West  iioth  StrMl 
« York  City     1918 


Health  Problems  of  National  Council  of  Education 
and  American  Medical  Association 


Fig.  86. — Can  you  suggest  an  eleventh? 


272  HOME  AND  COMMUNITY  HYGIENE 

PROBLEMS 

1.  Make  a  set  of  health  rules  for  the  guidance  of  a  grade  teacher. 

2.  What  polite  habits  or  customs  should  a  teacher  endeavor  to  make 
habitual  ? 

3.  Name  the  nearest  town  which  has  a  school  nurse;  medical  inspection; 
pje,  ear  or  teeth  clinics. 

4.  Recall  your  own  experience  in  other  schools;  in  what  ways  were 
the  health  interests  not  sufficiently  guarded? 

5.  Prepare  an  illustrated  poster,  a  decorative  set  of  rules,  or  a  wall 
sign  that  will  help  children  (of  a  given  age)  correct  careless  unhygienic 
habits. 

6.  Suggest  ways  of  emphasizing  personal  cleanliness  standards  to 
children. 

7.  Grade  one  school,  using  the  headings  in  this  chapter  for  the  main 
points  of  consideration. 

8.  What  are  the  most  needed  changes  in  the  school  building  with  which 
you  are  connected  ? 

9.  How  many  of  the  problems  given  in  the  chapter  on  air  can  be  used 
for  this  chapter  ? 

10.  How  can  you  secure  a  school  nurse  or  a  medical  inspector  for  your 
local  school  ?   Plan  an  exhibit  to  secure  community  interest  and  co-operation. 

See  Reference  List  at  end  of  Appendix. 


CHAPTER  XVI 
OTHER  COMMUNITY  UNITS   OR  RELATIONS 

LIBRARIES,    CHURCHES   AND   OTHER   ASSEMBLY   PLACES 

Ventilation  the  Main  Problem. — With  libraries,  lecture  halls, 
and  churches  the  main  problems  are  those  of  ventilation.  How  in- 
completely such  buildings  are  ventilated  is  illustrated  by  the  diffi- 
culties experienced  by  a  church  in  New  Jersey  some  twenty  years 
ago.  Two  furnaces  with  separate  chimneys  and  heating  systems 
were  installed;  but  the  janitor  could  never  get  more  than  one  to 
burn  at  any  time,  though  which  one  he  could  never  tell  until  after 
he  started  the  fires.  The  firm  that  installed  the  furnaces  tinkered 
and  adjusted,  but  without  success.  Finally  a  jack-of -all-trades  in 
the  neighborhood  broke  a  pane  of  glass  in  the  cellar  window,  and 
since  then  both  furnaces  can  burn  at  the  same  time.  Before  that 
one  furnace  chimney  was  necessary  to  provide  the  fresh  air  for  the 
other  furnace.  Too  low  chimneys  (because  of  the  architectural 
design  used)  may  give  similar  trouble;  each  chimney  should  be  at 
least  two  feet  higher  than  the  highest  part  of  the  roof. 

Ventilation  Standards. — In  small  localities  such  buildings  are 
often  open  but  once  or  twice  a  week.  At  such  times  they  may  be 
overcrowded;  the  ventilation  usually  falls  far  below  the  optimum 
standards  advised  by  Kimball:  (1)  thirty  feet  of  fresh  air  per 
occupant  per  minute;  (2)  no  occupant  more  than  twenty-five  feet 
from  a  fresh-air  register  or  nearer  than  six  feet  to  a  vent  register ; 
( 3 )  at  least  one  fresh-air  and  one  vent  opening  to  each  thirty  occu- 
pants. Instead  of  uniform  conditions  of  this  kind,  people  usually 
sit  in  overheated,  stuffy  rooms,  which  are  closed  tightly  almost 
before  they  leave  to  remain  closed  until  the  next  session,  when  the 
same  used  air  is  heated  and  used  over  again.  The  musty  smell  we 
associate  with  such  buildings  is  not  the  "  atmosphere' of  erudition '' 
or  "  the  odor  of  sanctity,"  but  the  odor  of  musty  carpets,  mildewed 
books,  and  stale  air.  The  proneness  to  sleep  during  lectures  and 
sermons  is  often  less  a  criticism  of  the  preacher  and  lecturer  than 
of  the  ventilating  system  and  its  management. 

Sunlight. — The  stained-glass  windows  of  our  churches  yield  a 
18  273 


274  HOME  AND  COMMUNITY  HYGIENE 

"  dim  religious  light "  that  has  certain  restful  and  emotional  values, 
but  little  germicidal  power;  in  libraries  the  demand  for  shelf  room 
limits  unduly  the  space  given  to  windows.  The  practice  of  keeping 
the  shades  down  between  periods  of  occupancy  deprives  such  rooms 
of  the  beneficial  effect  of  sunlight. 

Library  Books. — In  libraries  the  question  most  often  brought 
up  is  in  regard  to  books.  Tuberculosis  may  adhere  to  books,  espe- 
cially to  the  saliva-moistened  thumbed  areas.  Examination  of 
library  books  for  mouth  bacteria  rarely  shows  streptococci  in  more 
than  one  in  twenty  books.  This  indicates  disease  transfer  through 
books  is  not  very  great.  Billings,  a  former  medical  officer  of  ISTew 
York  City,  holds  that  99  per  cent,  of  the  cases  of  communicable 
disease  are  transmitted  from  person  to  person,  and  almost  never  by 
fomites,  such  as  books.  Many  libraries  disregard  the  possible  dan- 
gers from  books  entirely.  School  books,  which  are  often  more  closely 
associated  with  communicable  diseases,  might  profitably  be  disin- 
fected before  being  used  again.  Standing  them  for  a  day  or  two 
on  one  end  with  leaves  spread  out  loosely  on  an  open  window  sill 
or  porch  in  sunlight  will  probably  weaken  or  kill  off  ordinary  human 
organisms. 

In  New  York  City  the  health  department  passes  on  to  the 
Public  Library  notifications  of  communicable  diseases,  and  the  ad- 
dresses are  compared  with  the  out-book  list  at  the  libraries.  Small- 
pox books  are  collected  by  the  health  department  and  burned;  diph- 
theria books  are  also  turned  over  to  the  department  of  health  for 
decision  regarding  disposal.  Books  exposed  to  measles,  etc.,  are 
boxed  at  the  libraries  and  at  intervals  such  collections  are  sent  to 
the  health  department  for  treatment  or  cremation  at  its  discretion. 

Moving  Picture  Halls. — In  moving  picture  halls  the  special 
attending  evils  are  overcrowding  and  insufficient  ventilation.  Such 
rooms  are  necessarily  kept  dark  and  this  tends  to  cut  down  the 
window  space;  suitable  shades  are  expensive,  and  they  are  difficult 
to  keep  well  adjusted  (to  avoid  flapping  and  the  entrance  of  light)  ; 
and  the  tendency  is  to  keep  the  windows  shut  or  to  resort  to  insuffi- 
cient ventilating  shafts,  etc.  People  are  crowded  too  close  to  each 
other;  under  such  conditions  organisms  discharged  from  the  nose 
and  mouth  are  most  readily  transferred.  The  large  number  of 
children  in  the   audiences  increases  the  transfer  of  many  com- 


OTHER  COMMUNITY  UNITS  275 

municable  diseases,  for  children  are  especially  susceptible  to  certain 
diseases  (Fig.  53). 

In  churches,  granges,  ladies'  aid  societies,  etc.,  the  social  side 
has  its  peculiar  dangers.  Food  is  too  often  contributed  from  homes 
below  the  sanitary  standards.  The  general  lack  of  running  water 
and  the  short  supply  of  any  watfer,  especially  hot  water,  in  such 
buildings,  do  not  generally  allow  the  proper  washing  of  dishes  and 
spoons,  nor  of  the  hands  of  those  who  serve  or  otherwise  handle 
the  food. 

EESTAUEANTS^    ICE   CREAM   PARLORS,   SODA   WATER   STANDS, 
BAKERIES,  ETC. 

Protection  of  Food. — Food  displayed  in  windows  or  on  coun- 
ters should  be  under  glass  to  protect  it  from  dust,  flies,  and  from 
patrons  who  are  not  always  considerate  about  handling  rolls,  candies, 
etc.  Very  often  while  making  selections  or  payment,  packages, 
books,  and  even  muffs  are  deposited  temporarily  upon  such  trays  of 
food,  or  dirty  fur  cuffs  and  neck  pieces  are  allowed  to  brush  over 
them.  High-grade  stores  now  insist  that  clerks  handle  candies  with 
scoops  or  tongs.  Such  rulings  are  a  great  help,  but  they  do  not  en- 
tirely protect  one  against  the  empty-headed;  recently  in  one  of  the 
shops  of  a  candy  firm  known  on  both  sides  of  the  Atlantic  a  patron 
watched  an  idle  clerk  toying  with  her  candy  tongs,  using  them 
against  her  teeth  to  open  and  shut  her  lips.  Even  so,  her  tongs 
were  probably  safer  than  her  fingers  would  be,  but  she  had  failed 
entirely  to  grasp  the  reason  for  the  ruling  regarding  candy  hand- 
ling. Unbroken  wrappers  should  be  extended  to  include  oiled 
paper  covers  or  boxes  for  bread,  cakes,  and  pies. 

Care  of  Utensils. — Important  also  is  the  care  of  glasses,  dishes, 
etc.,  used  in  serving  soda,  ice  cream,  and  even  hot  drinks,  for  they 
are  rarely  hot  enough  to  disinfect  the  glasses  or  cups.  All  such 
utensils  should  be  washed  in  hot  soapy  water  and  also  rinsed  in 
clean,  hot  water  and  preferably  drained  dry.^  Only  fresh  towels 
should  be  used  for  drying  dishes  or  glasses ;  napkins  used  by  patrons 

^  The  automatic  arrangements  for  washing  glasses  should  provide  a 
slanting  rack  for  draining  after  washing,  especially  if  they  are  re-used 
before  they  are  dry.  Some  of  the  devices  now  used  do  not  come  up  to  the 
standards  described  above. 


276  HOME  AND  COMMUNITY  HYGIENE 

should  never  be  used.  Cream  dishes  are  difficult  to  wash,  and  spe- 
cial care  is  necessary  to  remove  the  greas}'  film.  Paper  dishes, 
spoons  and  cups  should  be  more  generally  used  in  eating  places. 
The  dishes  can  be  set  in.  silver  holders,  etc.,  if  appearance  is  im- 
portant. In  such  matters  cleanliness  comes  first  with  all  sensible 
people. 

Other  Regulations. — Such  places  should  provide  adequate 
toilet  facilities  for  the  workers  with  running  hot  water,  soap,  and 
paper  towels  for  hand  washing.  All  employees  serving  food  or 
handling  uncooked  foods  should  be  shown  to  be  free  from  tuber- 
culosis or  other  communicable  diseases.  Typhoid,  dysentery,  diph- 
theria, and  meningitis  carriers  should  be  eliminated  by  tests  made 
at  least  once  a  year. 

HOTELS 

All  that  was  said  in  the  preceding  section  concerning  restaurants 
applies  to  hotels.  Most  of  the  subject-matter  in  the  chapter  on  the 
home  is  also  applicable  here.  Large  hotels  make  advertising  use 
of  their  finely  equipped  kitchens,  and  that  usually  insures  a  certain 
degree  of  cleanliness. 

Personal  Habits  of  Attendants. — Objectionable  personal 
habits  may  destroy  the  values  aimed  at  in  sanitary  regulations. 
For  example,  in  many  of  the  hotels  the  waiters  wear  white  wash 
gloves  at  banquets,  etc.,  especially  in  the  summer  time  when  per- 
spiration is  to  be  considered;  it  is  little  pleasure  to  watch  such 
waiters  rub  their  mouths  or  noses  with  the  gloved  hand  before  hand- 
ling your  spoon  or  plate. 

Towels  and  Napkins. — ^Towels  and  napkins  laundered  outside 
by  supply  houses  should  be  sent  home  wrapped  in  fresh  paper. 
Tied  piles  of  folded  napkins  with  unprotected  edges  are  often  carried 
by  drivers  in  soiled  hands  or  piled  on  the  floor  of  carts  not  washed 
since  soiled  ones  were  collected.  The  dangers  may  not  be  great, 
but  the  situation  is  not  exactly  pleasant  to  contemplate. 

Finger  Bowls. — Finger  bowls  should  have  a  fresh  paper  lin- 
ing, or  be  sent  to  the  kitchens  to  be  washed  just  as  thoroughly  as 
the  other  dishes  are  washed. 

Drinking  Water. — Hotels  might  well  be  required  to  post  pla- 
cards and  print  on  the  bills-of-fare  the  source  of  the  drinking  water 


OTHER  COMMUNITY  UNITS  277 

and  the  treatment  to  which  it  has  been  subjected  by  the  hotel  or 
the  community. 

Bedrooms  and  Bathrooms. — Eoom  occupants  should  wash 
bathing  and  toilet  appliances  thoroughly  before  using  them.  Cham- 
bermaids in  even  the  best  hotels  too  often  dry  the  basins,  tooth 
mugs,  etc.,  with  towels  carried  from  room  to  room;  slightly  soiled 
towels  collected  as  they  go  from  room  to  room  are  sometimes  used, 
too. 

Bedding  cannot  be  entirely  replaced  for  each  patron.  But  clean 
sheets  can  and  should  be  supplied.  To  save  a  trip  to  the  distant 
linen  room,  or  rather  than  wait  for  the  next  supply  of  laundry,  a 
chambermaid  will  often  use  a  once-used  sheet  as  the  under  sheet. 
In  such  cases  both  sheets  should  be  replaced  by  fresh  ones.  Sheets 
should  be  long  enough  to  protect  the  occupant  from  contact  with 
used  or  soiled  blankets  or  other  bed  coverings.  For  some  time  even 
intelligent  people  took  as  a  joke  the  nine-foot  sheet  rule  demanded 
by  one  of  our  States,  failing  entirely  to  see  its  hygienic  importance. 

DENTAL  OFFICES,  BARBER  AND  MANICURE  SHOPS 

Dental  Offices. — Dentists'  tools  should  be  steam-sterilized, 
boiled  or  chemically  disinfected  after  each  patron.  This  applies  to 
the  water  syringe  and  to  the  water  glasses,  which  are  sometimes  left 
out  when  the  other  appliances  are  treated. 

Hairdressers  and  Barbers. — Hairdressers  and  barbers  should 
boil  or  steam-sterilize  combs,  cups,  razors,  brushes,  etc.,  after  each 
patron.  Towels  are  often  dried  without  washing  and  then  used 
again.  Drying  on  radiators,  etc.,  does  not  necessarily  destroy  bac- 
teria. Neck  boils  or  carbuncles  and  other  skin  infections  are  often 
traced  to  barber  shops;  if  organisms  chance  to  get  on  any  broken 
surface,  such  as  razor  cuts,  or  the  places  chafed  by  stiff  collars,  in- 
fection is  much  more  likely  to  occur.  Individual  appliances  are 
sometimes  left  or  kept  at  barber  shops,  manicure  shops,  etc.,  but 
too  many  people  have  the  habit  of  dropping  into  any  convenient 
place. 

Manicure  Shops. — The  danger  in  manicure  shops  is  mainly 
limited  to  infection  through  breaks  in  the  skin;  cutting  the  cuticle 
too  deep  may  give  similar  opportunity  for  entrance.  Little  infec- 
tion is  probably  transferred  through  manicuring. 


278 


HOME  AND  COMMUNITY  HYGIENE 


In  all  the  above  situations  there  is  the  esthetic  side  to  be  con- 
sidered, which  should  make  us  demand  absolute  cleanliness  in  the 
appliances  used.  Assistants  suffering  from  such  diseases  as  acne 
(G),  gonorrhoea  (G),  and  syphilis  (G)  should  not  be  employed  in 
any  of  these  places. 


WAITIXG  EOOMS  IN  STORES,  RAILROAD   STATIONS,  ETC. 

Drinking  Arrangements. — Individual  cups  should  be  provided 
free  or  for  sale  in  automatic  holders.  Drinking  fountains  should 
be  absolutely  safe,  if  used  at  all  (Fig.  79). 


D         P 


^ 


Fig.  87. — In  this  faucet  notice  that  there  is  plenty  of  room  for  the  glass,  so  that  drip  from 
the  plunger,  P,  need  not  run  into  the  glass.     Make  sure  the  faucets  you  use  are  safe. 

The  faucets  of  water  coolers  are  often  short,  tiny  plugs  or 
plungers  which  allow  the  water  to  drip  over  the  plunger  soiled  by 
contact  with  many  fingers,  or  over  the  fingers  themselves  into  the 
glass  of  water  (Fig,  87).  Faucets  are  made  short  to  avoid  break- 
age ;  longer  ones,  which  bring  the  fingers  and  plunger  drip  outside 
the  drinking  glass,  should  be  substituted. 

Toilet  Arrangements. — Toilet  rooms  should  be  light  and 
roomy;  good  illumination  should  be  provided  at  night.  Nails  should 
be  provided  for  hanging  wraps,  also  a  low  shelf  for  heavy  or  bulky 
articles  and  a  higher,  smaller  one  for  small  articles  (purse,  etc.). 
Each  patron  can  secure  a  safe  surface  for  such  personal  articles  by 
using  a  fresh  paper  towel. 

The  toilet  seats  should  be  U-shaped;  most  water  flushing  ar- 


OTHER  COMMUNITY  UNITS 


279 


rangements  can  be  worked  by  the  foot.  Knobs  can  be  turned  by 
the  gloved  hand  or  with  protecting  bits  of  paper  toweling.  Arrange- 
ments for  washing  the  hands  are  necessary,  and  should  always  be 
provided. 


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Fig.  88. — A  fly  trap.     Sweetened  bread  is  placed  on  the  board  base  underneath  the  trap; 
after  feeding,  the  flies  fly  upward  through  the  opening  and  are  held  in  the  top  of  the  cage. 


STORES  AND   MARKETS 

Care  o£  Food. — Food  used  raw  or  not  done  up  in  packages 
should  be  kept  at  least  two  feet  above  the  floor  line.  Dogs  and 
cats  should  be  kept  out  of  such  places.  It  is  not  uncommon  to  see 
the  "  store  cat "  walking  over  the  food,  or  sunning  herself  in  the 
window.  Eats  and  mice  can  be  effectively  cleaned  out  by  traps ;  and 
traps  do  not  add  to  the  sanitary  problems  as  cats  do. 

Flies. — Flies  should  be  kept  out.  It  is  difficult  to  control  flies. 
Sticky  fly-strips  from  the  ceiling,  wire  fly  traps   (Fig.  88),  and 


280  HOME  AND  COMMUNITY  HYGIENE 

formalin-poisoned  bread  (see  Appendix)  are  valuable  aids,  if  rightly 
managed.  The  prompt  removal  of  refuse  from  the  back  room  or 
the  back  step,  and  keeping  the  stable  free  from  manure  are  both 
important  aids  in  decreasing  the  number  of  flies.  Flies  breed  in 
horse  manure;  12,000  larvs  (G-)  were  once  counted  in  one  pound 
d¥  horse  manure.  The  stable  should  be  as  far  from  the  store  as 
possible.  Prompt  removal  of  all  refuse,  including  garbage,  is 
necessary. 

Scoring  Shops. — Wood  suggests  scoring  stores  and  markets 
for  such  points  as  freedom  from  flies  and  refuse.  This  might  be 
applicable  in  communities  where  there  are  a  number  of  stores.  In 
smaller  communities  something  ought  to  be  done  in  stimulating 
a  friendly  competition,  e.g.,  having  the  local  paper  announce  in  May 
that  patrons  are  invited  to  compare  the  number  of  flies  found  in 
each  store  on  a  definite  date,  e.g.,  the  first  of  June — or  Fourth  of 
July.  Such  measures  develop  a  certain  sensitiveness  to  the  fly 
question  on  the  part  of  patrons  as  well  as  shopkeepers. 

Other  Essentials. — Toilets  and  opportunities  for  washing  the 
hands  are  essential.  Only  fresh  water  should  be  used  to  freshen 
vegetables;  and  the  pails,  tubs,  etc.,  should  be  cleaned  and  dried 
between  periods  of  use. 

LAUNDRIES 

Dangers. — The  dangers  from  laundries  come  from  two  condi- 
tions: (1)  The  washing  and  ironing  processes  may  be  so  imper- 
fectly performed  that  the  organisms  originally  present  are  not  de- 
stroyed; in  such  cases  they  may  be  transferred  to  other  clothing 
washed  with  the  infected  clothing.  (2)  Finished  laundry  may  be 
infected  by  its  treatment  after  washing  and  ironing  have  been 
completed. 

Effect  of  Laundry  Processes  on  Bacteria. — The  methods  of 
washing  and  ironing  vary  so  greatly  that  it  is  difficult  to  discuss 
this  topic  briefly.  Washing  with  hot,  soapy  water,  boiling  in  hot 
water,  and  rinsing  in  one  or  more  waters  are  fairly  imiform  parts 
of  the  washing  process  in  most  homes.  To  these  are  added  drying 
in  fresh  air  and  sunlight,  and  ironing.  Under  such  home  condi- 
tions there  is  practically  no  danger  from  infected  linen.  Drying  at 
the  high  temperatures  used  in  the  drjang  rooms  of  the  large  laun- 


OTHER  COMMUNITY  UNITS  281 

dries  destroys  harmful  bacteria.  Ironing  by  hand,  by  machine,  and 
by  mangle  usually  means  an  effective  degree  of  heat.  This  was 
tested  by  clothes  which  were  soaked  with  known  bacteria.  After 
ironing,  these  bacteria  could  not  be  recovered,  if  the  clothes  had 
been  ironed  to  give  the  custojnary  degree  of  smoothness.  There  is 
a  little  danger  that  seams  and  thick  edges  may  not  be  so  completely 
affected  by  ironing;  if  clothes  are  run  too  rapidly  through  the 
mangle,  complete  safety  is  not  assured.  If  the  preliminary  proc- 
esses of  washing  and  drying  are  properly  done,  ironing  usually  com- 
pletes satisfactorily  the  safeguards  to  health. 

Private  or  Home  Laundries. — Home  washing  and  ironing 
processes  are  usually  efficient  as  indicated  above.  Private  laun- 
dresses may  do  the  work  in  the  same  thorough  way.  Often  they  are 
much  less  careful.  Too  often  the  clothes  are  dried  in  the  over- 
crowded living  room ;  they  may  not  be  kept  apart  from  other  soiled 
clothes — even  after  ironing.  Such  intimate  association  with  the 
family  makes  possible  transfer  of  tuberculosis  and  other  commu- 
nicable diseases. 

Steam  Laundries. — Many  of  the  large  steam  laundries  wash 
the  clothes  after  they  are  packed  into  large  nets  (90  per  cent,  in  the 
recent  New  York  City  investigation).  These  tightly-packed  nets 
are  not  always  penetrated  sufficiently  by  the  hot  water  and  the  soap. 
In  some  tests  over  half  of  the  sugar  and  salt  left  in  the  interior  of 
such  nets  was  recovered  unmelted.  Soiled  clothes  in  such  nets 
may,  therefore,  transfer  organisms  to  other  clothing.  "  Wet  wash 
clothes  "  which  are  returned  to  the  various  homes  may  contain  dan- 
gerous organisms.  Most  so-called  "  hand  laundries  "  give  their 
washing  over  to  steam  laundries  and  dry  the  returned  wet-washed 
clothes  in  little  crowded  rooms  which  are  also  usually  occupied  for 
living  purposes.  They  have,  therefore,  no  advantages  over  the  ordi- 
nary low-grade  private  laundress.  Many  "  hand  laundries "  are 
merely  receiving  stations  for  steam  laundries,  all  the  laundry  proc- 
esses being  done  at  the  central  steam  laundries.  Schroeder  and 
Southerland  recommend  that  all  clothes  washed  by  steam  laundries 
be  dried  on  the  same  premises  to  insure  the  complete  destruction  of 
objectionable  bacteria.  In  the  self-contained  laundries  where  this 
is  done  the  high  temperature  used  in  drjdng  completes  the  process 
of  bacterial  destruction.  Colored  and  woolen  clothes  are  not  so 
satisfactorily  treated  as  other  clothes. 


282  HOME  AND  COMMUNITY  HYGIENE 

Chinese  Laundries. — On  the  whole,  Chinese  laundries  com- 
pare very  favorably  with  other  commercial  laundries.  They  are 
apparently  more  careful  to  keep  clean  clothes  from  contact  with 
soiled  ones  (sorting  ironed  clothes  on  separate  places,  or  clean  iron- 
ing boards).  Fewer  of  them  lived  in  such  close  contact  with  the 
clothes  as  in  the  small  "  hand  laundries.^^  In  these  the  sprinkling 
of  clothes  for  ironing  was  more  often  done  by  a  blow-can,  which  is 
worked  by  the  mouth  to  throw  a  spray  of  water  over  the  clothes. 
The  florist's  bulb,  the  bottle  sprinkler,  or  the  plain  whisk  broom  are 
preferable;  as  several  workers  often  use  the  same  mouth  spray, 
there  is  danger  that  they  may  transfer  mouth  organisms  to  the 
clothes,  also.  Such  sprays  operated  by  mouth  are  prohibited  in  a 
few  of  our  cities. 

General  Criticisms. — In  general,  more  care  should  be  taken  to 
separate  clean  and  soiled  linen  in  the  receiving,  sorting,  and  pack- 
ing rooms;  clean  and  soiled  clothes  should  not  be  packed  together 
into  the  same  delivery  wagon,  and  clean  wagons  should  be  used  to 
deliver  washed  clothes.  Wet-washing  in  nets  does  not  usually  allow 
sufficient  action  of  the  hot  water  and  soap.  Disinfecting  chemicals 
strong  enough  to  do  what  ordinary  laundry  processes  ought  to  do 
are  either  too  expensive  or  injurious  to  clothes.  Wet  washing  is 
"  a  possible  menace  to  the  public  health."  Infected  helpers  in  the 
final  sorting  room  may  be  eliminated  by  requiring  examinations 
for  such  diseases  as  tuberculosis  at  least  once  a  year.  Although  net 
washing  is  not  a  satisfactory  process,  clothes  dried  in  the  steam 
laundries  in  highly  heated  rooms,  and  ironed  by  hand,  machine,  or 
properly  heated  mangles,  may  be  quite  free  from  undesirable  organ- 
isms, if  proper  attention  is  paid  to  the  final  handling  and  the 
delivery  (wagons,  etc.). 

Community  Laundries. — Laundries  should  be  definitely  under 
municipal  control,  and  compelled  to  conform  to  certain  standards, 
e.g.,  temperature  of  drying  rooms,  final  handling  only  by  people 
free  from  communicable  diseases,  and  separation  of  living  and 
laundry  operations.  In  San  Francisco,  for  example,  an  application 
for  establishing  a  laundry  can  be  granted  only  after  a  public  hear- 
ing. A  few  places  conduct  municipal  or  community  laundries; 
gome  of  these  unfortunately  warrant  the  criticisms  given  above. 


OTHER  COMMUNITY  UNITS  283 

PROBLEMS 

1.  One  city  has  a  municipal  wash  house  where  housekeepers  in  the 
neighborhood  may  bring  their  family  washing.  What  arguments  for  such 
an  arrangement? 

What  rules  should  govern  the  management? 

2.  Make  a  set  of  sanitary  rules  for  the  janitorial  staff  of  public 
buildings. 

3.  One  city  has  a  janitor  school  for  its  custodians  of  buildings.  What 
would  you  have  taught  in  such  a  school? 

4.  Where  in  our  school  system  can  persons  be  taught  the  health  essen- 
tials which  should  be  understood  by  grocery  clerks,  waitresses  and  other  food 
handlers?  What  rules  of  personal  action  can  you  suggest  as  a  basis  of 
such  instruction? 

5.  What  problems  of  public  conveyances  (street  cars,  sleeping  cars) 
are  not  answered  by  the  Chapters  XIII,  XVI  and  VI? 

6.  Beds  or  bedding  should  be  aired  for  at  least  one  hour  each  day.  How 
long  are  they  aired  in  your  boarding  house  ?    Are  they  sunned  as  well  ? 

7.  Table  napkins  are  too  often  piled  into  a  common  drawer.  This  is 
especially  undesirable  where  strangers  eat  together,  as  in  boarding  houses. 
If  paper  napkins  are  not  substituted,  a  protective  covering  should  be  used, 
as  in  tuberculosis  sanatoriums.  Can  you  design  a  simple  but  attractive 
case  or  envelope?  It  need  not  be  closed  on  all  sides  as  envelopes  are,  if  the 
cover  projects  beyond  the  napkin;  it  should,  of  course,  be  washable  or 
easily  laundered. 

8.  Which  is  the  best  store  (market,  ice  cream  saloon,  or  laundry)  in 
your  locality  from  the  point  of  care  of  utensils  {e.  g.,  care  of  chopping 
block,  spoons,  finger  bowls )  and  personal  habits  of  the  employees  ? 

9.  Make  a  set  of  rules  to  post  for  the  guidance  of  restaurant  employees, 
which  would  tend  to  prevent  disease  transfer  to  patrons. 

10.  Make  similar  simple  rules  for  a  mother  to  use  in  establishing  proper 
habits  in  her  child.  Give  concrete  illustrations  that  would  make  the  dangers 
realistic  to  a  child  of  5 ;  to  a  child  of  10. 

11.  In  how  many  of  the  situations  or  conditions  discussed  in  this 
chapter  should  non-spitting  regulations  be  enforced? 

See  Reference  List  at  end  of  Appendix. 


CHAPTER  XVII 
INFANT  WELFARE 

Infant  mortality  is  not  a  complete  index  of  infant  welfare  con- 
ditions, because  there  is  more  to  the  question  than  the  number  of 
the  dead  and  the  number  of  the  living.  Mere  survival  means  little ; 
the  important  thing  to  the  individual  and  to  the  community  is  the 
physical  and  mental  equipment  with  which  the  survivor  faces  the 
coming  years. 

Nevertheless,  mortality  figures  are  a  very  convenient  way  of 
calling  attention  to  the  whole  problem  of  infant  welfare.  High 
death  rates  always  mean  conditions  which  should  be  remedied  in 
part,  at  least.  Even  discounting  somewhat  for  the  fact  that  correct 
birth  figures  are  difficult  ^  to  obtain,  the  wide  range  in  infant  mor- 
tality rates  given  in  the  next  paragraph  indicates  that  the  conditions 
are  very  unequal,  even  in  the  parts  of  the  world  where  health  is  a 
matter  of  general  concern. 

Mortality  Figures. — Figures  compiled  seven  years  ago  credit 
Australia  with  but  75  deaths  per  thousand  births  (see  Chapter 
XXIV  for  method  of  estimating  such  statistics),  while  Prussia  has 
157  and  Hungary  195  deaths  per  thousand  births.  Russia  has  a 
very  high  infant  mortality  rate — over  250,  and  in  some  localities  as 
high  as  370,  as  estimated  by  the  recent  Red  Cross  commission  to 
Russia.  In  the  United  States  the  average  is  lower,  124  per  thousand 
births  in  the  1911  census  report,  though  some  localities  run  up  to 
200;  in  ISTew  York  State  and  in  New  York  City  also  the  rates  are 
below  100;  the  1917  records  for  New  York  City  give  the  infant 
mortality  rate  at  but  89  per  thousand  births.  The  last  report  for 
England  and  Wales  gives  for  1916  the  lowest  rate  ever  recorded 
for  those  countries,  94  per  thousand  births. 

It  is  only  during  the  last  few  years  that  there  has  been  a  decided 
drop  in  the  infant  mortality  rates.    Some  attribute  this  to  the  de- 

'  Due  to  the  incomplete  registration   of  birtlis    (explained  mainly  by 
i^orance,  carelessness  and  illegitimacy)    and  to  the  fact  that  the  age  is 
often  incorrectly  given,  e.g.,  ages  under  one  year  being  given  as  one  year. 
284 


INFANT  WELFARE  285 

creased  birth  ^  rate,  and  while  this  doubtless  had  its  effect,  most  of 
it  must  be  due  to  the  bettering  of  general  hygienic  conditions  {e.g., 
pure  water,  which  affects  dysentery  and  diarrhoea)  and  still  more  to 
efforts  designed  to  protect  the  babies  themselves. 

The  need  in  the  United  States  is  shown  by  the  following  state- 
ments made  by  reputable  authorities :  One  in  every  eight  babies  dies 
the  first  year;  in  the  registration  area  (G)  in  any  year  one-fifth  of 
th  deaths  of  all  ages  are  those  of  children  less  than  one  year  old, 
and  one-quarter  of  the  total  deaths  are  those  of  children  less  than 
two  years  old. 

Causes  of  Infant  Mortality. — The  causes  of  high  infant  mor- 
tality rates  are  numerous  indeed.  They  may  be  best  discussed  under 
(1)  inheritance,  (2)  conditions  at  and  before  birth,  (3)  general 
environmental  conditions  following  birth :  e.g.,  fresh  air,  food,  care, 
and  cleanliness,  and  (4)  specific  infant  diseases  (not  covered  by  the 
preceding  topics). 

Inheritance. —  (1)  Technically,  actual  diseases  are  not  inherited ; 
real  inheritance  is  rare  even  in  syphilis  (see  next  paragraph).  What 
the  child  does  inherit  is  a  tendency  to  this  or  that  disease  {e.g., 
tuberculosis)  through  malformed  organs  {e.g.,  contracted  chest) 
or  general  low  vitality  and  resistance;  family  histories  of  certain 
diseases  may  be  due  to  such  inheritance  {e.g.,  cancer  or  tuberculosis) . 
In  many  cases,  however,  family  diseases  may  be  due  to  the  many 
repeated  opportunities  for  infection  {e.g.,  tuberculosis). 

(2)  At  birth  children  may  be  found  to  be  infected  with  the 
venereal  diseases,  less  often  with  tuberculosis.  While  such  par- 
ents infected  with  syphilis  do  not  always  have  infected  children,  the 
chances  are  that  the  children  will  not  escape;  figures  support  this, 
if  we  include  the  large  number  of  still  births,  which  are  in  so  great 
part  traceable  to  this  disease.  Definite  malformations  (bone,  vis- 
ceral organs),  general  physical  deficiency,  as  well  as  mental  weak- 
ness ranging  from  slight  subnormality  to  actual  idiocy  are  common 
manifestations  of  such  pre-birth  conditions.  Blindness  is  often  duc; 
to  gonorrhoea,  acquired  usually  at  the  time  of  birth,  even  when 

^At  first  reading  this  seems  impossible,  because  infant  deaths  are  esti- 
mated in  proportion  to  the  births,  but  figures  show  that  increases  in  the 
birth  rate  increase  the  relative  number  of  infant  deaths,  and  vice  versa. 


286  HOME  AND  COMMUNITY  HYGIENE 

born  of  an  infected  mother,  or  by  organisms  from  the  hands  of  the 
doctor  or  nurse. ^ 

Conditions  at  and  Before  Birth. —  (3)  Pre-natal  conditions 
relating  to  the  physical  health  of  the  mother  (overwork,  malnutri- 
tion) have  an  important  effect  upon  the  health  of  the  child.  Igno- 
rance causes  many  a  physical  handicap;  economic  conditions  are 
responsible  for  still  more,  however  (Fig.  91). 

In  foreign  countries  where  a  larger  number  of  married  women 
are  employed  in  the  industries,  we  find  more  definite  laws  tending 
to  secure  better  conditions  for  the  periods  preceding  or  following 
birth.  In  France,  teachers  and  .women  in  the  government  employ 
are  given  two  months  leave  with  treatment  and  full  pay.  In  Italy, 
all  factories  employing  fifty  or  more  women  must  provide  a  room 
where  they  may  feed  their  infants,  and  extra  time  (one-half  to  one 
hour)  must  be  allowed  for  caring  for  the  children.  In  this  country 
but  four  States  (1917)  have  passed  industrial  laws  covering  this 
same  field.  Massachusetts  and  Vermont  require  cessation  of  labor 
for  two  weeks  before  and  four  weeks  after  birth;  Connecticut,  for 
four  weeks  before  and  four  weeks  after  birth;  and  New  York,  for 
four  weeks  after  birth.  The  lifting  of  heavy  weights  by  women  is 
prevented  (pulleys,  etc.)  in  but  one  State,  Massachusetts,  and  there 
but  for  weights  of  75  pounds  or  more.  When  one  recalls,  for  ex- 
ample, the  revelations  of  recent  investigations  of  the  conditions  of 
women  working  in  twine  and  cordage  mills  employing  over  17,000 
women  and  children,  and  remembers  that  in  some  cases  the  spray 
and  drip  from  the  wet  fibres  often  wet  the  clothes  to  above  the 
waist  line,  and  that  water  may  collect  in  such  pools  that  the 
workers  are  forced  to  go  barefooted,  we  can  see  that  our  laws  are 
most  insufficient.  We  cannot  excuse  our  inadequate  legislation  by 
showing  that  we  employ  fewer  women  than  men  in  industry. 

Ignorance  on  the  part  of  parents  is  responsible  for  many  un- 
favorable pre-birth  conditions.  Nationalities  in  the  same  crowded 
districts  will  vary  astonishingly  in  the  infant  mortality  rates.  These 
mortality  differences  are,  pf  course,  partly  due  to  after-birth  con- 
ditions, such  as  feeding  and  lack  of  cleanliness  mentioned  in  the 
next  section  of  this  chapter.  They  very  often  vary  greatly  with 
racial  lines;  in  Chicago  (1910)  the  highest  rates  were  in  the  Polish 

^  Other  bacteria,  ordinarily  quite  harmless,  may  also  multiply  in  the 
delicate  eye  membranes,  '•ausing  blindness. 


INFANT  WELFARE  287 

sections  rather  than  the  less  crowded  Italian  districts.  Wood  con- 
siders the  Poles  and  Slavs  responsible  for  the  high  infant  death 
rate  of  Chicago.  Another  factor  is  the  lack  of  suitable  healthful 
exercise  for  the  mother.  The  habit  of  staying  indoors  and  the 
more  or  less  enforced  sedentary  life  are  both  important  con- 
siderations when  one  reflects  that  the  mother  must  supply  sufficient 
oxygen  for  two  beings.  Constipation  and  digestive  disturbances 
are  other  problems  receiving  too  little  attention  at  this  time.  There 
is  great  need  of  better  pre-birth  advice  than  the  baby-clinics  and 
baby-welfare  stations  can  give.  Every  town  and  every  county  should 
have  a  sufficient  number  of  free  clinics  hours  (some  at  night)  for 
advising  prospective  mothers  who  cannot  afford  medical  aid. 

Midwives. — Another  important  factor  in  birth  fatalities  is  the 
midwife.  Over  40  per  cent,  of  all  births  are  attended  only  by  mid- 
wives  ;  this  usually  means  no  pre-natal  medical  advice  at  all.  When 
one  recalls  the  absolute  ignorance  of  most  midwives  and  the  low 
type  of  clients  which  make  up  the  majority  of  their  patients,  the 
opportunity  for  disease  transfer  is  appalling.  Almost  as  great  is 
the  evil  resulting  from  their  ignorant  superstitions  regarding  care, 
feeding,  etc.  Some  southern  cities  have  had  appalling  death  rates 
traceable  to  the  negro  midwives.  Until  a  community  can  provide 
free  clinical  advice  to  prospective  mothers,  and  hospital  beds  or 
nurses  in  the  homes  for  all  the  poor  mothers,  the  midwife  is  the 
only  recourse  left  the  poor.  Meantime,  it  is  at  least  in  the  power 
of  every  community  to  enforce  the  registration,  education  (by  lec- 
tures and  demonstrations),  and  licensing  of  all  who  are  to  act  as 
midwives. 

Environmental  Factors. — The  conditions  in  early  life  most 
important  are  food,  care,  cleanliness,  rest,  temperature,  and  avoid- 
ance of  disease  transfer. 

Food. — The  natural  food  is  milk,  of  course.  Mother's  milk  is 
undeniably  better  than  cow's  milk.  Eighty  per  cent,  of  all  deaths 
in  the  first  year  are  among  the  bottle-fed  babies,  though  the  bottle- 
fed  represent  but  20  per  cent,  of  the  babies.  Diarrhoea  is  nearly 
three  times  as  common  in  cow-fed  as  in  breast-fed  babies.  This  in- 
dicates that  breast  feeding  should  be  used  whenever  possible.  The 
money  spent  for  cow's  milk  could  be  more  profitably  spent  for  better 
food  for  the  mother.  If  cow's  milk  must  be  used,  it  should  be  pas- 
teurized unless  '^certified"  coVs  milk  (see  p.  86)  is  used.    Mixed 


288  HOME  AND  COMMUNITY  HYGIENE 

cow's  milk  is  more  -uniform  than  the  milk  of  a  single  cow,  and  is 
now  preferred  to  "one  cow's  milk."  Any  lack  in  vitamines  (G) 
due  to  pasteurization  can  be  replaced  by  giving  the  baby  daily  one 
to  three  teaspoons  of  orange  or  tomato  juice,  or  potato  water. 
Simple  directions  for  the  home  pasteurization  of  milk  are  given  in 
the  Appendix.  (See  also  Chapter  IV  on  Milk.)  Cow's  milk  is 
poorer  in  sugar,  about  the  same  in  fat,  and  richer  in  protein  and 
minerals  than  human  milk.  When  modified  to  secure  the  preferred 
protein  proportion,  by  adding  equal  amounts  of  boiled  water  or 
boiled  barley  water,  the  other  substances  fall  below  the  proportion  in 
mother's  milk.  It  is,  therefore,  suggested  that  the  top  milk  be 
poured  off  for  the  baby's  use.  This,  containing  more  of  the  fat,  is, 
when  modified,  nearer  the  desired  proportions.  Sugar  can  easily 
be  added,  cane  sugar  or  preferably  milk  sugar.  The  exact  modifica- 
tions necessary  vary  with  the  individual  and  the  age;  the  advice  of 
doctors  or  nurses  should  be  secured  when  possible.  Some  of  the 
large  dairies  prepare  a  modified  milk  according  to  the  directions  of 
local  physicians. 

Pasteurized  or  certified  milk  should  be  kept  cool  until  used. 
Bottles,  nipples,  as  well  as  the  milk,  should  be  kept  from  flies ;  they 
should  be  cleaned  promptly,  soaked  in  soda  water,*  cleaned,  dried,^ 
and  if  possible  sunned  after  use. 

Goat's  Milk. — Goats  are  remarkably  free  from  tuberculosis  (no 
trace  in  over  13,000  goats  slaughtered) ;  and  goat's  milk  is,  there- 
fore, strongly  recommended  by  many  people.  The  milk  is  fully  as 
digestible  as  cow's  milk,  and  children  not  doing  well  on  other  milk 
foods  have  sometimes  been  greatly  benefited  by  a  change  to  goat's 
milk.  Many  people  could  keep  a  goat  who  lack  space  for  a  cow; 
the  goat  is  also  a  cleaner  animal  than  the  cow  (fecal  matter  rarely 
adhering  to  the  coat,  etc. ) .  There  is,  however,  one  danger  in  goat's 
milk.  Goats  in  the  Mediterranean  countries  frequently  transfer 
Malta  fever  through  the  milk,  and  the  wholesale  use  of  goats  in  this 
country  might  be  dangerous,  although  the  disease  is  not  common 
in  our  goats  at  present. 

Pasteurized  Milk. — The  early  prejudice  against  pasteurized 
milk  is  almost  dispelled.    If  any  mothers  or  nurses  still  need  to  be 

*  About  one  teaspoonful  to  a  quart  of  water. 

^  Some  prefer  to  keep  the  nipples  (after  thorough  washing)  in  satu- 
rated solution  of  boric  acid. 


INFANT  WELFARE  289 

convinced,  see  the  table  on  page  84.  There  are  many  other  figures 
to  support  the  value  of  pasteurized  milk.  In  one  experiment  one 
hundred  and  ten  babies  averaged  a  daily  gain  of  .4312  ounces  on 
raw  milk,  but  gained  .4607  ounces  when  transferred  to  pasteurized 
milk.  This  may  seem  slight,  but  it  means  over  half  a  pound  a  year. 
Babies  are  often  overfed.  Such  a  baby  cries  because  he  has 
indigestion  from  too  much  food,  not  because  "  he  is  hungry."  One 
and  a  half  ounces  of  milk  to  each  pound  weight  is  a  common  stand- 
ard. In  sickness  the  amount  of  milk  should  be  reduced.  Cereal 
water  is  a  good  temporary  substitute  for  sick  babies ;  continued  in- 
disposition demands  medical  advice,  for  babies  "  die  very  easily." 


ClfiAt^,  Clv'*'^^  h^'f^es 


T)irty     h< 


r/i 


e  5 


rli&s    atidi     cLiyt 


Fig.  89. — Proportion  of  diarrhcea  cases  developing  in  homes  of  babies  classed  as  above. 
(Based  on  figures  in  Health  News,  July,  1915.) 

Water  is  a  necessary  part  of  every  baby's  diet.  The  addition  of 
foods  other  than  milk  should  be  adapted  to  the  age  and  digestive 
peculiarities  of  the  individual  child.  Most  parents  begin  outside 
feeding  too  soon.  Lately,  attention  has  been  called  to  the  danger  of 
giving  a  child  too  much  of  a  new  food  the  first  time.  There  is  great 
danger  with  some  foods  (such  as  eggs  and  strawberries)  that  a 
child  may  be  thus  made  a  "food-sensitive"  (G,  also  p.  210). 

Cleanliness  of  food  has  already  been  mentioned,  but  general 
cleanliness  needs  emphasis  also.  Bathing  has  soothing  and  stimu- 
lating effects  of  inestimable  value.  The  prompt  washing  of  diapers 
soiled  with  excreta  apparently  improved  the  health  markedly  in  one 
experiment  in  tenement  districts.  Intestinal  diseases  are  often  fly- 
borne;  avoidance  of  conditions  that  attract  flies  and  fly-screening 
are  important  aids  (Fig.  89). 

Temperature. — Hot  weather  has  a  marked  effect  upon  the  health 
of  babies;  death  and  sickness  rates  rise  with  or  just  after  intensely 
19 


290 


HOME  AND  COMMUNITY  HYGIENE 


hot  periods  (Fig.  90).  As  Winslow  has  pointed  out,  most  babies 
cannot  stand  the  double  handicap  of  poor  milk  and  hot  weather. 
The  three-month  summer  death  rate  is  often  equal  to  that  of  the 
remaining  nine  months.  Clothing  should  be  modified  with  tem- 
perature ;  many  layers  of  clothing  and  rubberized  diapers  should  be 
avoided  in  very  hot  weather.  Cool  roof  gardens,  recreation  piers 
(though  too  crowded  and  noisy),  or  dry  basement  rooms  should  be 
available  part  of  the  day  for  every  child  condemned  to  summer  in 
warm  climates.  Hospitals  are  slowly  adding  cooled  rooms  where 
such  respite  from  intense  summer  heat  may  be  secured. 


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Fig.  90.— The  relation  between  temperature  and  deaths  from  diarrhoea.    Five-day  averages 
for  children  under  two  years  of  age  in  Chicago,  1915. 

Care  Important. — Care,  as  a  life  factor,  is  most  important. 
How  important  has  been  emphasized  by  almost  all  writers  on  infant 
welfare,  by  citing  the  low  death  rates  of  the  babies  in  such  emergen- 
cies as  the  siege  of  Paris  and  prolonged  strikes,  such  as  those  of 
the  Lancashire  cotton  mills,  where  the  death  rate  fell  to  40  per 
cent,  despite  the  almost  famine  conditions  that  existed. 

Eosenau  states  that  infant  mortality  increases  in  proportion  to 
the  working  time  mothers  spend  outside  the  home,  even  when  the 
increased  income  is  used  for  increased  comforts  in  the  home  (Figs. 
91  and  92).  The  mortality  rates  for  factory  centres  support  this. 
Figures  of  twenty  to  thirty  years  ago  give  an  average  rate  of  174.9 
per  thousand  births  for  cities;  but  the  rates  for  factory  towns  at 
that  time  are  illustrated  by  the  following:  239  for  Fall  Eiver,  222 
for  Lowell,  and  213  for  Lawrence.    In  1914,  when  the  mortality  rate 


INFANT  WELFARE 


291 


for  New  York  City  was  but  94  per  thousand  births,  other  cities  had 
disgracefully  high  rates:  Watervliet,  160;  Eensselaer,  178; 
Cohoes,  205 ;  and  Lackawanna,  352. 

Other  Factors. — Minor  factors,  such  as  illegitimacy,  the  age 
of  the  parents,  and  the  possible  effects  of  infant  life  insurance  are 


Rat* 


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Fia.  91. — What  argument  here  for  minimum  wage?    For  price  fixing  of  rent,  food,  coal,  etc.? 

all  economic  phases,  which  deserve  serious  attention,  but  which 
need  only  to  be  stated  to  be  realized. 

Special  Diseases. — Diarrhoea  and  similar  intestinal  disturb- 
ances cause  one-quarter  to  one-third  of  all  infant  diseases.  These 
are  in  great  part  due  to  the  food  conditions;  indigestible  foods  are 
predisposing  factors,  though  the  diseases  are  mainly  due  to  organ- 


292 


HOME  AND  COMMUNITY  HYGIENE 


isms  conveyed  in  the  food.     The  direct  relation  between  pasteurized 
and  raw  milk  and  diarrhoea  is  shown  by  the  table  on  page  84, 

Eespiratory  diseases  play  too  large  a  part  in  infant  mortality. 
They,  with  diarrhoea,  cause  about  50  per  cent,  of  all  infant  deaths. 
C^ontact  with  adults  suffering  with  any  respiratory  infection  should 
be  avoided. 

Per  Cant  of  Mothers  Gainfullij  Lrh- 
p/eyed  in  Manchester,  h.H.,  During   year 
Fsllowina  Baby's   Birth    When    Fathera 
£arned  Specified   Qmounis. 

Per  Cent 


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Fig.  92. — What  connection  between  this  and  the  infant  mortality  rates  of  manufacturing 

cities?     (See  Fig.  91.) 

Helpful  Suggestions. — What  to  do  has  been  implied  through- 
out in  the  preceding  discussion  of  the  causes  of  infant  mortality. 
How  to  do  it  may  not  be  quite  so  clear. 

Milk  Stations. — Almost  a  generation  ago  the  first  baby  milk 
stations  were  started  in  this  country  for  the  purpose  of  providing 


INFANT  WELFARE  293 

good  milk  for  the  babies.  Doctor  Josephine  Baker  says  the  problem 
of  infant  welfare  is  20  per  cent,  milk  and  80  per  cent,  education 
of  the  mothers,  and  the  history  of  the  milk  stations  proves  this. 
The  first  milk  stations  in  the  United  States  were  the  Straus  milk 
stations  in  New  York  City,  1889,  providing  good  milk  free  or  at 
cost  price.  From  providing  good  milk  to  showing  the  mothers  how 
to  pasteurize  the  milk  was  a  natural  step.  jSTow  many  of  the  stations 
have  not  only  nurses  hut  physicians  in  attendance  several  hours  a 
day  for  consultation,  not  only  regarding  the  baby's  condition,  but 
often  as  advisers  to  the  mothers  during  the  pre-birth  period.  In 
many  stations  a  welfare  pamphlet  is  sent  to  the  mother  as  soon  as 
the  birth  is  registered.  One  of  the  visiting  nurses  soon  follows  this 
up,  visiting  the  child  about  every  ten  days;  such  nurses  in  New 
York  City  average  150  babies  each. 

Baby  Clinics. — Baby  clinics  are  even  more  necessary  in  the 
country  than  in  the  city,  and,  as  recommended  for  other  conditions, 
a  travelling  baby  clinic  is  really  quite  feasible,  once  the  people  know 
that  they  want  it.  They  should,  of  course,  be  combined  with  an 
advisory  clinic  for  expectant  mothers. 

Day  Nurseries. — Day  nurseries,  too,  need  no  commendation. 
If  mothers  must  work,  a  safe,  clean  place  must  be  provided  for  the 
children.  In  the  more  progressive  cities  a  system  of  mother's  pen- 
sions make  day  nurseries  less  necessary.  Day  nurseries  should  be 
open  to  inspection  by  the  board  of  health,  and  conform  to  the  laws 
of  such  boards;  they  should  provide  only  healthy  attendants,  and 
segregate  infected  children  or  suspects,  if  such  are  received. 

Other  Aids. — Eest  farms  or  some  vacation  scheme  for  mothers 
and  babies  is  also  desirable.  When  we,  as  a  nation,  realize  all  the 
forms  the  "  ounce  of  prevention  "  can  take,  it  will  not  be  necessary 
to  enumerate  to  an  intelligent  community  the  advantages  to  the 
community  as  well  as  to  the  individual  of  such  infant  welfare  work. 
Pending  the  time  when  adequate  attention  can  be  given  by  mothers 
and  nurses,  the  Little  Mothers  societies  are  well  worth  while;  in 
ISTew  York  City  over  17,000  children  help  in  this  way.  But  the 
problem  is  not  a  child's  problem,  and  should  be  dignified  by  the 
serious  attention  of  the  most  intelligent  and  influential  members  of 
the  community.  The  State  of  Iowa  has  recently  appropriated 
$25,000  annually  for  research  in  child  welfare.     (See  p.  373.) 

The  Pre-school  Period. — Attention  is  now  being  directed  to 


294  HOME  AND  COMMUNITY  HYGIENE 

the  pre-school  period,  under  five  or  six,  which  has  not  shared  all  the 
benefits  gained  by  infants  (under  one  year) . 

Sleep. — Most  of  the  conditions  discussed  before  apply  here. 
Still  more  might  we  emphasize  the  need  of  rest  or  sleep — not  only 
the  daily  nap,  which  parents  find  it  easier  to  "  let  go,"  but  a  long- 
night  sleep.  Our  slum  streets  are  full  of  tiny  children  long  after 
nightfall ;  it  is  rare,  even  among  the  more  prosperous  and  more  in- 
telligent, for  a  child  of  five  to  have  the  eleven  to  thirteen  hours  of 
sleep  physiologists  recommend  (Fig.  86).  If  each  one  of  us  could 
spend  a  continuous  period  of  twenty-four  hours  in  a  tenement  dis- 
trict where  the  din  of  trolleys,  elevateds,  and  trucks  is  only  equalled 
by  the  noise  of  dumb  waiters,  garbage  cans  and  phonographs  and 
the  constant  turmoil  of  a  constantly  changing  house  personnel  of 
day  and  night  workers,  and  the  cries  and  shouts  of  next-door 
neighbors  whose  windows  open  directly  into  yours,  one  would  under- 
stand why  sleep  is  impossible  except  from  sheer  exhaustion,  and 
recognize  that  we  haven't  done  our  duty  to  children  until  we  have 
made  for  them  "  a  quiet  place."  Kindergartens  and  such  refuges 
help,  but  until  we  have  no  slums,  American  ingenuity  should  de- 
vise some  scheme  for  quiet  rest  or  sleep  not  possible  now  day  or 
night  in  the  homes  of  many  thousands  of  children.  Why  not  night 
nurseries  as  well  as  day  nurseries  ?  It  would  help  many  a  nervous, 
delicate  child  who  does  not  need  day  nursery  care.  Such  buildings 
could  easily  be  used  in  "  two  shifts." 

Food. — WTiile  children  of  three  or  more  years  of  age  are  less 
aifected  by  a  somewhat  poorer  grade  of  milk,  food  is  still  a  most 
important  factor.  Fruits  and  vegetables  should  now  be  an  impor- 
tant part  of  the  diet.  (See  Chapter  III,  especially  vitamines.) 
Eickets  and  lack  of  growth  are  directly  food  problems. 

Defects. — The  defects  that  show  up  so  appallingly  in  school 
children  should  be  detected  here,  and  remedied  in  time  to  prevent 
any  handicap  after  entering  school. 

Contagious  Diseases. — Contagious  diseases  should  be  avoided 
• — even  the  mildest  (see  Fig.  53).  No  one  can  predict  the  full  ex- 
tent of  the  after-effects  of  any  disease.  People  who  object  to  scien- 
tific vaccination  against  smallpox  will  repeatedly  expose  their  chil- 
dren to  diseases  spread  by  nasal  discharges,  filthy  flies,  or  fecal 
wastes  without  a  qualm.  Whooping  cough  causes  more  deaths  than 
scarlet  fever,  and  in  some  years  more  than  any  other  communicable 


INFANT  WELFARE  295 

disease.  The  need  for  greater  protection  of  little  children  from 
communicable  diseases  is  indicated  by  the  high  death  rate  of  chil- 
dren under  five;  96  per  cent,  of  the  total  deaths  occur  in  this  group. 

PROBLEMS 

1.  What  private  organizations  interested  in  infant  welfare  are  help- 
ing in  your  community? 

2.  Does  your  city,  county  or  state  do  anything  to  promote  infant 
welfare? 

3.  Make  a  curve  showing  the  infant  death  rate  per  1000  births  for  your 
community  for  the  last  ten  years. 

4.  Make  a  similar  curve  giving  a  comparison  of  summer  and  winter 
death  rates  for  infants. 

5.  Spot  the  infant  deaths  for  two  continuous  years  on  a  map  of  your 
community.  What  factors — overcrowding,  nationality,  poverty,  etc. — seem 
most  important? 

6.  Show  why  the  term  "slaughter  of  the  innocents"  is  often  rightly 
used  in  relation  to  certain  communities. 

7.  Debate  the  following:  Fifty  per  cent,  of  all  infant  deaths  are 
preventable. 

8.  Make  a  list  of  ten  "Don'ts  for  the  Baby." 

9.  Plan  an  exhibit  on  Child  Welfare,  describing  what  charts,  posters 
and  other  exhibits  you  would  have. 

10.  How  can  you  help  the  Children's  Bureau  in  its  campaign  to  save 
100,000  babies  in  1918?  Write  that  Bureau  in  Washington  for  information. 
What  materials  can  be  secured  from  the  sources  mentioned  on  p.  373  ? 

11.  Answer  question  11  on  p.  91. 

12.  Discuss  the  need  (see  publications  of  the  Children's  Bureau,  and  of 
the  Child  Health  Organization  of  New  York  City)  of  emphasis  on  the  pre- 
school period.  Make  a  short  popular  article  suitable  for  a  mothers'  meeting 
or  a  kindergarten  circular. 

See  Reference  List  at  end  of  Appendix. 


CHAPTER  XVIII 


MIDDLE  AGE 


'  Life  Expectation  Averages. — Infant  welfare  work  in  the  last 
forty  years  has  so  improved  the  conditions  of  little  children  that 
the  average  expectation  of  life  for  children  under  five  has  been 
raised  from  forty-one  to  fifty-one  years,  an  increase  of  ten  years. 
In  1879,  as  indicated  by  the  following  table,  children  who  had  safely 
reached  the  age  of  ten  would  live,  on  an  average,  43.8  years  longer. 
In  1909,  the  average  expectation  would  be  4G.9,  or  three  years  more. 

As  shown  in  the  table  given  below,  this  increase  becomes 
negligible  at  middle  age;  and  the  expectation  of  life  averages  less 
after  forty  years  is  reached.  The  net  gain  is  fourteen  years,  how- 
ever, and  this  apparent  drop  may  only  mean  that  those  who  would 
have  died  at  five  or  ten  fall  out  at  thirty  or  forty.  Of  course,  we 
really  can't  decrease  the  death  rate;  every  one  born  must  die  some 
time,  and  it  is  a  question  how  long  death  can  be  deferred — or  how 
much  we  can  decrease  the  death  rate  for  given  ages.  Many  feel 
that  if  the  needs  of  late  youth  and  middle  age  were  properly  met, 
this  drop  after  thirty  would  not  occur — that  a  gain  would  be  pos- 
sible even  here. 

Age  Changes. — There  are  at  middle  age  certain  natural  changes 
in  the  body  that  predispose  to  disease.     The  blood-vessels  are  less 

Table  for  New  York  City  Showing  Probable  Years  of  Life  for  Variotts 
Ages  for  Two  Periods  a  Generation  (Thirty  Years)  Apart  (Guilfoy) 


Average 

Average 

Age 

expectation  iu 
1879-1881 

expectation  in 
1909-1911 

Gain 

Loss 

Under    5 

41.3 

51.9 

10.6 

5 

46.3 

51.1 

4.8 

10 

43.8 

46.9 

3.1 

20 

35.8 

38.3 

2.5 

30 

29.6 

30.5 

.9 

40 

23.9 

23.4 

.5 

50 

18.3 

16.8 

1.5 

60 

13.0 

11.3 

1.7 

70 

8.9 

7.2 

1.7 

80 

6.4 

4.3 

2.1 

Total  gain  21.9 

Total  loss.. 7.5 

296 


MIDDLE  AGE 


297 


able  to  make  the  usual  adjustments.  This  is  partly  due  to  the 
increase  in  fatty  connective  tissue  characteristic  of  age,  which  tends 
to  compress  such  important  organs  as  the  heart  and  other  blood- 
vessels ;  this  condition  not  only  afEects  the  distribution  of  the  blood, 
but  may  also  affect  directly  such  soft  glands  as  the  kidneys.  The 
walls  of  the  blood-vessels  are  themselves  less  elastic  with  increasing 
age;  even  where  actual  rupture  of  the  vessels  does  not  occur  (apo- 
plexy, hemorrhage)  the  distribution  of  the  blood  supply  is  mate- 
rially affected,  and  the  body  lacks  its  former  power  of  instant  and 
complete  adjustment  of  the  blood  supply. 

Obesity. — Obesity  has  many  disadvantages;  it  means  a  larger 
bulk  to  nourish  and  move  around,  and  entails  more  work  for  the 
muscles  and  the  organs  of  digestion  and  excretion.  H.  D.  Chapin 
says  that  the  prospect  of  a  long  and  vigorous  life  diminishes  as  the 
waist  line  bulges  beyond  the  chest  line.  Insurance  figures  show, 
for  given  age  and  height,  increasing  death  rates  with  the  increase 
in  weight;  they  also  show  that  a  decrease  in  the  death  rate  goes 
with  a  moderate  decrease  below  the  average  weight  for  a  given  age 
and  height.  The  tables  following  give  the  average  weights  for  men 
and  women  (pp.  297,  298).  Weights  slightly  below  these  are  shown 
by  life  insurance  records  on  page  298  to  be  more  favorable  to  vitality 
and  longevity.  It  would  probably  be  well  to  keep  one's  weight  ten 
to  fifteen  pounds  below  the  averages  given  here.  In  other  words, 
underweights  are  better  risks  than  even  average  weights. 


Symonds's  Table  of  Height  and  Weight  for  Men  at  Different  Ages 

Based  on  74,162  Accepted  Applicants  for  Life  Insurance 

{Medical  Record) 


Ages 

5  ft.    3  in 

4  in 

5  in 

6  in 

7  in 
Sin 
9in 

10  in 

11  in 

6  ft.    Oin 

1  in 

2  in 


15-24 

25-29 

30-34 

35-39 

40-44 

45-49 

50-54 

55-59 

60-64 

127 

131 

134 

136 

139 

141 

141 

141 

140 

131 

135 

138 

140 

143 

144 

145 

145 

144 

134 

138 

141 

143 

146 

147 

149 

149 

148 

138 

142 

145 

147 

150 

151 

153 

153 

153 

142 

147 

150 

152 

155 

156 

158 

158 

158 

146 

151 

154 

157 

160 

161 

163 

163 

163 

150 

155 

159 

162 

165 

166 

167 

168 

168 

154 

159 

164 

167 

170 

171 

172 

173 

174 

159 

164 

169 

173 

175 

177 

177 

178 

180 

165 

170 

175 

179 

180 

183 

182 

183 

185 

170 

177 

181 

185 

186 

189 

188 

189 

189 

176 

184 

188 

192 

194 

196 

194 

194 

192 

140 
143 
147 
151 
156 
162 
168 
174 
180 
185 
189 
192 


298 


HOME  AND  COMMUNITY  HYGIENE 


Stmonds's  Table  op  Height  and  Weight  for  Women  at  Different  Ages 

Based  on  58,855  Accepted  AppHcants  for  Life  Insurance 

{McClure's  Magazine) 


15-19 

20-24 

25-29 

30-34 

35-39 

40-44 

45-49 

50-54  55-59 

60  64 

\it.  11  in 

5ft.    0  in 

111 

113 
115 
117 
120 
123 
125 
128 
132 
136 
140 
144 

113 
114 
116 
118 
122 
125 
128 
132 
135 
140 
144 
147 

115 
117 
118 
120 
124 
127 
131 
135 
139 
143 
147 
151 

117 

119 
121 
123 
127 
130 
135 
137 
143 
147 
151 
155 

119 
122 
124 
127 
131 
134 
139 
143 
147 
151 
155 
159 

122 
125 
128 
132 
135 
138 
143 
146 
150 
155 
159 
163 

125 
128 
131 
134 
138 
142 
147 
151 
154 
158 
163 
167 

128 
130 
133 
137 
141 
145 
149 
153 
157 
161 
166 
170 

128 
131 
134 
137 
141 
145 
149 
153 
156 
161 
166 
170 

126 
129 

1  in 

132 

2  in 

136 

3  in 

140 

4  in 

144 

5  in 

148 

6in 

Ti'' 

7in 

155 

8  in 

160 

9  in 

165 

10  in 

169 

The  Relation  op  Ovterweight  to  Death  Rates 


Overweight 

Death  rate  increase 

5  pounds 

8  per  cent,  higher 
18  per  cent,  higher 
32  per  cent,  higher 
49  per  cent,  higher 
60  per  cent,  higher 
70  per  cent,  higher 
85  per  cent,  higher 

15  pounds 

30  pounds 

40  pounds 

50  pounds 

60  pounds 

70  pounds 

The  Relation  of  Underweight  to  Death  Rates 


Underweight 

Death  rate  decrease 

5  pounds 

3  per  cent. 

5  per  cent. 
3  per  cent. 
Average  mortality 

6  per  cent,  higher 

15  pounds 

30  pounds 

40  pounds 

50  pounds 

Diet. — Food  is  an  important  consideration  for  the  middle-aged. 
Most  people  eat  too  heartily;  meats  tend  to  form  too  large  a  part 
of  the  diet.  Excess  proteins  put  too  much  work  upon  such  excre- 
tory organs  as  the  kidneys.  Kidney  diseases  are  very  prominent  in 
the  lists  of  middle-aged  diseases,  ranking  one  of  the  main  causes  of 
illness  and  death;  these,  as  well  as  diabetes  and  many  circulatory 
affections  are  now  recognized  as  dietetic  problems. 

It  is  possible  that  the  cumulative  effects  of  slightly  injurious 


MIDDLE  AGE  200 

substances,  such  as  lead,  benzoic  acid,  or  other  food  adulterants,  may 
have  a  predisposing  effect  upon  the  diseases  of  middle  life.  Be- 
cause of  this,  preservatives  are  limited  by  the  federal  government 
in  foods  entering  into  interstate  commerce.  The  predisposing  ef- 
fects of  certain  occupations  which  naturally  assume  importance  at 
this  age  have  been  dealt  with  elsewhere  (Chapter  XX). 

Intestinal  Disorders. — Constipation — a  common  middle-age 
difficulty — may  be  partly  controlled  by  feeding.  Additions  such  as 
agar  (G)  (which  holds  water  tenaciously,  and  being  quite  indi- 
gestible gives  bulk  throughout  the  passage  through  the  intestine) 
are  helpful  in  many  cases  of  constipation.  Coarse  foods  usually 
have  an  indigestible  residue;  this  gives  bulk  and  has  a  stimulating 
effect  on  intestinal  movements.  Constipation  is  one  of  the  most 
difficult  situations  to  combat  without  recourse  to  drugs.  Since  these 
are  often  harmful,  it  is  much  better  to  stimulate  the  body  to  normal 
activity  by  modifications  in  the  diet  whenever  this  is  possible.  Xo 
treatment  can  compensate  for  the  retention  and  absorption  of  harm- 
ful substances  formed  in  the  intestine.  Such  clogging  of  the  in- 
testine may  lead  to  bacterial  invasion  (appendicitis,  peritonitis). 
Xatural  foods,  such  as  citrus  fruits,  rhubarb  and  grapes,  help  by 
the  same  fruit  acids  and  salts  which  are  prominent  in  some  patented 
laxatives. 

Effect  of  Illness. — Such  disturbances  or  diseases  as  adenoids, 
indigestion,  malaria,  chronic  colds,  all  have  their  predisposing  ef- 
fects, and  though  no  serious  illness  may  be  traced  to  any  one,  they 
affect  the  tone  and  resistant  power  of  the  body.  Mere  living  to  an 
old  age  does  not  disprove  this;  it  only  proves  that  an  individual 
survived  in  spite  of  such  handicaps,  and  gives  no  indication  of  his 
attainments  or  possibilities  without  them.  Severe  illnesses  are  to 
be  avoided.  Intelligent,  sensible  people  no  longer  cause  children  to 
contract  a  given  disease  to  "  have  it  over  with."  Its  special  sequelce 
(deafness  after  measles,  kidney  disease  after  scarlet  fever,  etc.)  are 
too  great  a  risk ;  and  the  general  effects  cannot  be  predicted  nor  pre- 
vented. Those  who  reach  "three  score  years  and  ten''  in  full 
vigor  are  not  the  invalids — nor  those  who  have  had  many  severe 
illnesses. 

Too  little  attention  is  paid  to  the  effects  of  illnesses  upon  the 
length  of  life.  There  is  some  truth  in  the  saying,  "  To  live  long 
one  must  have  an  incurable  disease  " ;  it  is  readily  seen  that  a  slow 


300  HOME  AND  COMMUNITY  HYGIENE 

or  chronic  disease  (wliicii  implies  a  certain  tolerance  to  the  disease 
on  the  part  of  the  affected  individual)  usually  exacts  from  the  in- 
dividual and  his  neighbors  a  degree  of  hygienic  observance  not 
common  to  the  well  individual. 

Diseases  of  Middle-age. — The  characteristic  diseases  of  middle 
age  include  the  "  degenerative  diseases/^  mainly  diseases  of  the 
heart  and  blood-vessels,  the  kidneys,  and  the  liver.  In  the  order  of 
their  importance  the  diseases  of  middle  age  are :  circulatory  diseases, 
tuberculosis,  kidney  diseases,  diabetes,  liver  diseases,  and  alcoholism. 
In  1913,  diseases  of  the  heart,  blood-vessels  and  kidneys  caused  over 
85,000  deaths  in  the  registration  area  (G)  of  the  United  States. 
They  are  now  twice  as  common  as  they  were  thirty  years  ago,  while 
such  diseases  have  decreased  in  Great  Britain. 

Care  regarding  food  (including  digestion  and  excretion)  and 
the  degree  and  extent  of  exercises  are  important  in  controlling  and 
preventing  circulatory  weakness  or  diseases,  kidney  and  liver  dis- 
eases, and  diabetes.  Tuberculosis  has  been  dealt  with  in  a  separate 
chapter  (Chapter  XIX). 

Cancer. — While  very  little  is  yet  known  about  cancer,  the  fol- 
lowing statements  may  be  useful  to  some  of  our  readers.  Cancer  is 
apparently  not  inherited  in  human  beings,  though  a  tendency  to 
cancer  may  be  transmitted.  People  low  in  vitality  or  resistance 
are  quite  susceptible,  as  shown  by  the  evident  relation  between  tuber- 
culosis and  cancer.  Cancer  is  often  distinctly  related  to  outside 
irritants — heat  (smoker's  lip  cancer  and  cattle-brand  cancers) ; 
chemicals  (X-rays,  and  cheek  cancers  of  the  eaters  of  the  lime- 
containing  huyo  of  the  Philippines)  ;  and  mechanical  irritants  (soot 
or  chimney-sweep  cancer).  Whether  or  not  they  are  also  bacterial 
in  origin  is  not  yet  definitely  known,  though  much  work  is  at  pres- 
ent being  done  on  cancer. 

The  one  important  thing  to  emphasize  in  cancer  is  that  cancer 
is  curable  in  its  early  stages.  Such  symptoms  as  any  unusual  bleed- 
ing, swelling,  especially  without  pain,  sores  of  the  lower  lip  or 
tongue,  and  irritation  in  warts,  moles,  etc.,  should  have  immediate 
attention.  Most  cases  reach  the  surgeon  a  year  or  more  after  the 
symptoms  were  first  noted.  Nearly  half  of  all  cancer  could  be  cured 
in  the  early  stages:  about  40  per  cent,  of  the  superficial  cancers, 
and  nearly  50  per  cent,  of  the  deep  cancers.  The  percentages  of 
cures  in  early  and  delayed  operations  are:  breast:  early,  80  per  cent. ; 


MIDDLE  AGE  301 

late,  25  per  cent. ;  lip :  early,  95  per  cent. ;  late,  60  per  cent. ;  tongue : 
early,  80  per  cent.;  late,  15  per  cent.  The  only  sure  cure  is  re- 
moval; X-rays  may  be  helpful  in  some  cases,  but  the  use  of  such 
substances  is  not  yet  on  an  unchallenged  basis.  Medicines  have  no 
direct  value. 

Alarming  statements  are  made  concerning  the  prevalence  of 
cancer.  It  is  more  common  in  women  than  in  men,  except  in  cer- 
tain predisposing  occupations.  Cancer  causes  one  death  in  eight  in 
women  over  forty ;  and  one  in  fourteen  in  men  over  forty.  Between 
the  ages  of  thirty-five  and  forty  the  cancer  deaths  are  much  higher 
among  women  than  men,  three  to  one.  There  are  75,000  deaths 
from  cancer  yearly  in  the  United  States.  This  increase  may  be  due 
to  the  deferred  death  rate  we  have  established;  more  people  now 
reach  middle  age,  when  these  diseases  develop.  Practically  90  per 
cent,  of  all  cancer  deaths  are  of  people  over  forty  years  old.  The 
average  cancer  death  age  is  fifty-nine  years,  while  the  average  tuber- 
culosis death  age  is  thirty-six  years.  Part  of  the  increase  in  cancer 
rates  is  due  to  the  better  diagnosis  now  obtainable. 

Adult  Examinations  or  Clinics. — Because  the  diseases  of  mid- 
dle age  are  to  a  great  degree  preventable  or  may  be  delayed  by 
dieting,  exercise,  etc.,  all  people  passing  thirty-five  should  have  a 
thorough  physical  examination  to  enable  them  to  make  the  neces- 
sary changes  in  habits  of  living.  The  ISTew  York  City  Health  De- 
partment and  industrial  concerns,  such  as  railroads  and  life  insur- 
ance companies,  have  had  their  employees  examined  at  successive 
intervals  with  promising  results.  At  least  10  per  cent,  of  the  sev- 
eral hundred  employees  of  the  New  York  City  Health  Department 
showed  "  decided  improvement  on  their  second  examination  "  by  the 
Life  Extension  Institute.  One  great  value  of  such  periodical  ex- 
aminations is  that  people  come  to  realize  that  such  diseases  are  not 
necessarily  fatal,  that  they  may  be  prevented,  or  that  fatalities  may 
at  least  be  delayed.  It  removes  the  fatalistic  attitude  toward  kid- 
ney disease,  diabetes,  and  even  cancer  formerly  so  common,  and 
brings  hope  into  the  life  of  many  an  individual  and  family. 

Large  organizations,  such  as  the  Life  Extension  Institute,  have 
been  formed  in  some  cities.  There  is  great  opportunity  for  a 
travelling  clinic  for  the  middle  aged  for  the  smaller  towns  and 
rural  communities.  Large  towns  should  support  regular  clinics, 
with  night  hours  for  people  who  are  not  free  during  the  daytime. 

See  Reference  List  at  end  of  Appendix. 


CHAPTEE  XIX 
,  TUBERCULOSIS 

Tuberculosis  is  discussed  in  a  separate  chapter  not  only  because 
it  is  the  most  fatal  of  all  communicable  diseases^  but  because  it  is 
so  often  unrecognized  in  its  early  stages,  and  untreated  during  its 
development,  thus  increasing  the  fatalities  in  those  already  af- 
fected, and  multiplying  the  new  cases  by  needless  exposure. 

Tuberculosis  a  Menace. — How  great  a  menace  it  is  to  our 
country  is  shown  by  the  following  figures :  There  are  in  the  United 
States  160,000  deaths  yearly  from  tuberculosis  (Fig.  93) ;  it  causes 
9  per  cent,  of  all  the  deaths;  every  third  death  between  sixteen  and 
sixty  is  due  to  tuberculosis;  the  clinical  cases  are  estimated  as 
averaging  ten  to  twenty  times  the  deaths,  making  1,600,000  to 
3,200,000  cases  of  tuberculosis  now  in  existence.  Others  have  esti- 
mated that  there  are  nearly  ten  million  people  now  living  in  the 
United  States  who  will  die  of  tuberculosis,  unless  better  preventive 
measures  are  enforced. 

Whole  countries  as  well  as  localities  often  pay  too  little  atten- 
tion to  the  spread  and  ravages  of  this  disease.  France,  with  an 
army  death  rate  of  tuberculosis  exceeded  only  by  typhoid,  had  not, 
at  the  outbreak  of  the  war,  taken  any  public  measures  to  control 
tuberculosis,  either  in  the  army  or  in  civilian  life,  and  there  was  not 
for  its  forty  million  people  one  single  governmental  hospital  bed 
for  tuberculosis  in  all  France — and  but  one  thousand  private  ones. 

Since  tuberculosis  is  a  preventable  disease  and  also  a  curable 
one,  it  is  most  important  that  accurate  information  regarding  these 
measures  should  be  available  to  every  individual,  and  especially  to 
those  who  have  charge  of  the  welfare  of  others,  particularly  to 
mothers,  teachers,  and  nurses.  The  first  thing  one  should  know  is 
how  the  disease  is  transmitted  to  man. 

Types  of  Tuberculosis. — ^There  are  two  t5^pes  of  tuberculosis 
pathogenic  for  man:  the  human  (Fig.  94)  and  the  bovine.  Both 
these  types  may  invade  various  regions  of  the  body;  the  most  com- 
mon sites  in  cow  and  in  man  are  the  lungs  (Fig.  95),  the  ali- 
mentary canal,  the  glands  {e.g.,  neck,  near  the  alimentary  canal, 
302 


TUBERCULOSIS 


303 


and  in  cows,  the  udder),  bones,  and  joints.  When  open  lesions  or 
abscesses  occur,  organisms  may  leave  the  body  in  the  discharges 
from  such  lesions.  Commonly  these  bacteria  leave  the  cow's  body 
mainly  in  the  fasces  (Fig.  96)  and  milk;  in  man  they  leave  mainly 
through  the  mouth  discharges,  though  elimination  with  the  faeces 
is  not  uncommon. 

Method  of  Transfer  to  Man. — Bovine  tuberculosis  bacteria  are 
eliminated  with  the  milk,  or  fall  into  it  in  small  pieces  of  manure 


Fig.   93. — Thw  photograph  with  numerous  tubercles  (T)  on  the  omentum  or  fat  layer  shows 
the  reason  for  the  name  tuberculosis. 


or  stable  dust.  Less  often,  tubercular  meat  is  the  conveying  medium 
(see  Meat  Inspection,  Chapter  III),  Occasionally  they  may  be 
transferred  to  man  through  cuts  or  breaks  in  the  skin  {e.g.,  from 
tuberculous  udder  into  milker's  hand),  though  this  is  less  common. 
Human  tuberculosis  bacteria  may  find  their  way  into  the  water 
supply  and  be  taken  in  with  the  drinking  water;  more  commonly 
they  are  transferred  in  saliva  or  sputum  by  more  direct  contact 
(kissing,  common  cups,  pencils,  handkerchiefs,  etc.),  or  some  claim 
by  eating  food  on  which  small  particles  of  saliva  have  bten  recently 
deposited    (by  droplets,  fingers,  or  flies).     Tuberculosis)  bacteria 


304  HOME  AND  COMMUNITY  HYGIENE 

make  their  way  into  the  next  individual  by  way  of  the  lungs  or 
the  alimentary  canal. 

Experimental  work  has  now  demonstrated  that  tuberculosis  does 
not  necessarily  cause  lesions  or  visible  injury  at  the  point  of  en- 
trance. Tuberculosis  bacteria  rubbed  on  the  skin  of  perfectly 
healthy  guinea  pigs  caused  them  to  die  of  tuberculosis  of  the  in- 
ternal organs,  though  autopsy  showed  no  lesions  in  the  skin  itself. 
The  same  has  been  experimentally  shown  to  be  true  when  the 
entrance  is  through  the  intestinal  wall,  and  bacteria  entering  in 


Fig.   94. — Human  tuberculosis  organisms  and  blood-corpuscles;  the  tubercle  bacilli  have 
retained  the  red  stain  as  described  in  p.  214. 

that  way  may  cause  pulmonary  tuberculosis,  tuberculosis  of  the 
neck  glands,  etc. 

Such  experiments  have  established  the  importance  of  bovine 
organisms  as  causes  of  human  tuberculosis.    Other  proofs  are  found 

(1)  in  the  slightly  different  appearance  of  these  two  organisms, 
the  bovine  organism  being  shorter,  stouter,  and  less  granular;  and 

(2)  in  the  rabbit  test,  for  while  the  guinea  pig  is  susceptible  to 
both  diseases,  the  rabbit  is  practically  not  affected  by  the  human 
type.  It  takes  ten  to  one  hundred  times  as  many  of  the  human 
organisms  to  affect  the  rabbit,  causing  even  then  but  a  slight  local- 
ized tuberculosis.  Other  supporting  evidence  is  found  in  the  high 
mortality  of  small  groups  of  people  using  milk  from  tubercular  cows 


TUBERCULOSIS 


305 


{e.ff.,  five  out  of  fourteen  girls  in  one  boarding  school  died  of 
tuberculosis). 

Importance  of  the  Bovine  Type. — It  is  estimated  that  the 
bovine  type  causes  7  per  cent,  of  all  human  tuberculosis.  Children 
are  more  susceptible  than  adults  to  the  bovine  type ;  figures  by  Park 
and  others  give  the  following  percentages  for  bovine  infections 
among  the  tubercular:  Under  five  years,  27  to  49  per  cent.;  be- 


T 


y" 


Fig.    95. — Lung  cut   across,   showing   the    tubercles,   T,   or   hardened  areas  containing 
tuberculosis  organisms.    How  would  this  affect  long  absorption  of  oxygen? 

tween  five  and  sixteen  years,  16  to  25  per  cent. ;  and  above  sixteen 
years,  about  1  per  cent. 

The  bovine  type  probably  enters  through  the  tonsils  and  the 
small  intestine ;  it  is  associated  commonly  with  tuberculosis  of  the 
neck  glands,  or  in  the  region  of  the  alimentary  canal,  less  often  with 
bone  and  joint  infections,  and  practically  never  with  lung  infections. 


306 


HOME  AND  COMMUNITY  HYGIENE 


Protection  against  the  Bovine  Type. — Protection  from  the 
bovine  type  is  secured  by  pasteurizing  the  milk.  This  should  always 
be  done,  unless  the  milk  is  from  animals  tested  for  tuberculosis. 
(See  Tests,  p.  308.)  Apparently  healthy  animals  may  be  tuber- 
qular.  Cows  should  be  tested  at  least  once  a  year,  preferably  twice 
a  year,  as  a  large  number  of  cows  are  sometimes  found  to  be  tuber- 


u 


Fig.  96. — The  inner  surface  of  the  intestine,  showing  a  tuberculous  patch  or  ulcer,  U. 
Organisms  excreted  with  the  faeces  may  find  their  way  into  milk. 

cular — usually  about  14  per  cent.,  judging  from  a  recent  report 
co7ering  eighteen  States.  The  figures  for  the  United  States  are 
much  lower  than  those  in  the  European  countries — where  they  often 
reach  30  to  50  per  cent.,  apparently. 

Human  Type. — About  70  per  cent,  of  the  deaths  from  tuber- 
culosis are  due  to  pulmonary  infection ;  these  are  practically  all  due 
to  the  human  type  of  tuberculosis.  This  is  easily  explained  by  the 
greater  opportunity  for  transfer  from  man  to  man.    The  history  of 


TUBERCULOSIS  307 

tubercular  families  illustrates  this,  especially  since  tuberculosis  is 
not  very  often  acquired  before  birth ;  most  of  the  cases  in  little  chil- 
dren must  come  by  transfer  from  members  of  the  household.  One 
tubercular  nurse,  who  had  the  habit  of  tasting  the  food  of  her 
charges,  evidently  caused  the  deaths  of  four  little  children  within  a 
very  short  period. 

Predisposing  Factors. — It  is  recognized  that  there  are  dis- 
tinctly predisposing  factors  for  tuberculosis.  Such  external  condi- 
tions as  dampness  are  emphasized  by  some.  Damp  places  or  cli- 
mates probably  work  indirectly  as  depressants  to  the  general  health. 
In  sunny,  dry  climates  bacteria  die  off  more  quickly ;  transfer  would 
be  less  heavy  and  less  constant  in  such  climates,  and  recent  experi- 
ments have  shown  that  numbers  are  important  in  tuberculosis 
transfer.  It  takes  at  least  ten  organisms  to  inoculate  a  guinea  pig 
in  a  single  dose;  repeated  inoculations  of  smaller  numbers  may 
finally  break  down  the  body  resistance. 

Definite  predisposition  to  disease  is  probably  found  in  those  who 
have  chronic  lung  trouble,  coughs,  etc. ;  in  those  whose  vitality  and 
general  resistance  are  low,  who  live  or  work  in  dust-laden  or  irri- 
tating atmospheres  (see  Chapter  XX) ;  those  who  are  anasmic, 
flat-chested,  or  who  have  tubercular  family  histories.  Such  people 
should  endeavor  to  counteract  such  tendencies  or  predisposing  fac- 
tors in  every  way  (Fig.  97). 

Closeness  o£  Contact  Important. — Each  case  of  tuberculosis 
is  said  to  average  three  cases  of  transfer.  The  number  depends 
primarily  upon  the  length  and  intimacy  of  association.  About  80 
per  cent,  of  those  exposed  to  tubercular  infection  for  long  periods 
of  time  become  infected;  28  per  cent,  of  those  slightly  exposed,  or 
for  but  short  periods  of  time ;  and  but  8  per  cent,  of  those  in  chance 
or  occasional  contact  with  tubercular  people.  Children  seem  more 
easily  affected  than  adults.  This  may  be  due  to  the  more  direct 
contact  (fondling,  fingers  in  mouth,  etc.) ;  it  is  partly  due  to  the 
fact  that  most  people  have  tuberculosis  sometime  during  their  lives, 
and  the  adult  class  contains,  therefore,  more  immune  individuals 
than  we  find  among  children. 

Immunity  of  Adults. — Some  investigators  find  that  practically 

all   adults   respond   or   are   positive   to   the   tuberculin   test;    all 

over  fourteen  years  of  age  give  a  positive  reaction,  according  to  one 

authority.    This,  with  the  relative  immunity  of  adults  over  twenty- 

20 


308 


HOME  AND  COMMUNITY  HYGIENE 


Pre^^ent  the  White  Plague 

Know  n  a">  C^onsLimption  or  TLibcrcLilosis 

^^^pSSt^^^- ^■■'^''■■■■■-  " 

i 
1 

^^pI'-v^B^   - 

l^^^flv 

1 

1 

■age^.^r  -0^^^  ■  W7JL 

1 
1 

■n^^^^^^^^Btab^^^^ 

! 

"';;:;;.;               '         " 

SKhiN 

:              :                                     AN'OID 

ha^h  air  all  rhe  tinu             ■     '                      Bi  bathing  toul  an 

Sun>hiiK                                                            "Sun-(.l()di;ini*," 

Liglic,  t-kan  ruijni>                                          Dark,  dirt)  n)uni>. 

Wtll-choscn  food                                            Carcltss  eating 

Ample  sleep                                                    ('hronie  fatigue 

Exercise  in  the  open                         •           :    Lack  of  exercise 

Care  of  the  teeth  .                                           Xeglected,  decaying  teeth 

CJean  clothes                                                     Dust  and  smoke 

Clean. bod}- and  mind                                       Dissipation             , 

(Cheerfulness                                                      Worry 

TubiTCulosis  is  .curable  in  rln-  early  'stati;e.v  '  It  is  i-asier  U)  jiivxent  rlinn  to  cure 

J'atent  niediciiK's  will  nf)r  dcj' eirlicr 

200,000,  deaths  each  \  air— one  ci(.-ath.e\'en'  three  minutes 

from  tuberculosis  in  the  I'nitetl  States 

r'r.;|.riJ  <■:  \h  Jlvin,    D.  \V' J,  ;;;  U\  .1  rioili  Si.i,:                                                   (.oriHii!;ui..  on  Hfallii  l>i"hli.ms  f.t'NalEunal  Ci>lincil  crKducation 

\.,v.  ■,•  tk  i:.-.      j.yis                                                                                                                and  .Vmcri^-an  NkJicjIAssocijrir.n 

Fig.  97. — Are  these  rules  helpful  to  the  tubercular  only? 


TUBERCULOSIS  309 

five,  is  taken  as  indicating  that  practically  everyone  is  infected 
during  childhood;  such  people  are  usually  immune  to  tuberculosis, 
though  later  depressed  vitality,  strain,  etc.,  may  encourage  the  de- 
velopment of  latent  organisms,  causing  active  tuberculosis.  In  slow 
diseases  like  tuberculosis  the  body  often  acquires  a  tolerance  to  the 
organisms  which  is  most  remarkable.  "  Time  and  tolerance  "  are 
slogans  familiar  to  many  a  tubercular  patient.  When  the  reactions 
against  the  invading  bacteria  become  sufficiently  strong,  a  cure  is 
effected;  until  then,  a  tolerant  individual  may  at  any  time,  by 
strain,  worry,  overwork,  lack  of  proper  food,  lose  his  tolerance,  and 
become  very  ill  or  die  from  the  effects  of  the  organisms  before  they 
can  be  held  in  check. 

Prevention  of  Infection. — Prevention  of  the  spread  of  bovine 
tuberculosis  is  a  simple  matter  when  compared  with  the  many  op- 
portunities for  the  transfer  of  human  tuberculosis.  While  a  tuber- 
cular person  with  bacteria  in  his  sputum  may  be  a  perfectly  safe 
companion  if  he  uses  a  sputum  cup  properly,  it  is  not  uncommon 
to  see  people  who  spoil  it  all  by  one  careless  habit.  One  physician 
forbade  a  tubercular  mother  to  kiss  her  child ;  later,  when  with  tears 
in  her  eyes  the  mother  said  to  him,  "Doctor,  you  don't  know  how 
hard  it  is  for  me  to  refrain  from  kissing  my  baby,"  the  doctor  stood 
aghast  to  see  that  she  cooled  every  spoonful  of  "  pap  "  in  her  own 
mouth  before  feeding  it  to  her  child.  A  sputum  cup  is  little  protec- 
tion to  the  household,  if  the  patient  keeps  his  hands  at  his  mouth 
or  fails  to  wash  them  thoroughly  when  they  are  soiled  with  sputum, 
before  touching  common  articles. 

The  tables  on  pages  65  and  174,  with  the  details  in  this  chapter, 
make  the  numerous  opportunities  for  transfer  of  human  tubercu- 
losis perfectly  clear.^  It  might  help,  however,  to  state  the  general 
rules  to  be  observed  by  the  tubercular  and  by  those  associated  with 
them. 

Care  of  the  Tubercular. — Those  who  have  the  disease  should 
consult  the  best  authority  they  can  secure,  and  follow  his  directions 
as  completely  and  uniformly  as  possible.    High  altitudes  and  change 

^Though  most  organisms  die  off  rather  promptly  in  the  air  (drying, 
sunlight),  tuberculosis  is  usually  wrapped  in  a  covering  of  mucus,  and  such, 
organisms  have  been  known  to  survive  for  several  months.  A  few  may  also 
survive  in  water  for  months.  While  it  is  not  well  to  magnify  the  dangers  of 
this  dreaded  disease,  a  recognition   of  these  possibilities  is  probably  wise. 


310  HOME  AND  COMMUNITY  HYGIENE 

of  air  are  usually  very  helpful;  in  a  few  cases  they  may  not  com- 
pensate for  the  loneliness  of  the  patient.  Eemarkable  cures  are 
daily  wrought  right  at  home  in  many  cases  by  outdoor  living,  proper 
food,  etc.  Every  effort  should  be  made  to  make  the  tubercular 
realize  that  this  is  a  curable  disease,  for  cheerfulness  has  an  impor- 
tant effect. 

Community  Action. — Provision  should  be  made  for  the  care  of 
those  financially  unable  to  provide  suitable  and  adequate  care  for 
themselves.  This  will  include  sanatoriums  for  the  serious  or  urgent 
cases,  clinics  and  dispensaries  for  diagnosis,  advice  and  treatment 
of  suspected  and  beginning  cases,  day  camps  for  some,  night  camps 
for  those  who  must  work,  and  nurses  or  other  medical  aid  for 
visiting  homes,  and  for  school  and  factory  inspection.  Open-room 
or  open-air  schools  are  also  valuable  aids.  So  are  farm  colonies  for 
those  recovering  from  tuberculosis.  The  poorest  counties  could 
arrange  for  occasional  visits  from  a  travelling  clinic  force,  if  such 
were  organized  by  the  State  or  philanthropic  organizations.  But 
financial  help  will  be  necessary  in  many  cases  to  care  for  the  tuber- 
cular. They  are  tubercular  because  they  are  poor,  usually.  Crowded, 
poorly  ventilated  and  poorly  lighted  quarters,  insufficient  food, 
overwork  and  overworry  are  strong  predisposing  factors,  and  the 
health  problem  becomes  not  only  a  bigger  health  problem  but  a 
great  economic  one  as  well,  if  the  tubercular  are  not  cured  and  the 
non-tubercular  are  not  protected.  ISTo  community  can  afford  to  let 
tuberculosis  increase.  Eeduced  efficiency,  death,  debt,  dependent 
children  are  but  a  few  of  the  economic  problems  that  accompany 
the  tuberculosis  problem.  While  the  outlook  is  encouraging  (Fig. 
98),  the  figures  do  not  warrant  any  cessation  in  vigilance  in  combat- 
ing this  disease. 

Health  News  (1914)  describes  a  t}rpical  case  which  illustrates 
this.  A  painter  with  three  children  received  an  early  diagnosis  of 
tuberculosis.  He  tried  in  vain  to  enter  the  State  institutions; 
they  were  too  crowded.  Lacking  money,  he  was  not  properly  cared 
for  at  home,  and  died.  The  slender  savings  had  been  exhausted, 
and  the  overworked  wife  contracted  the  same  disease  and  died  within 
the,  year,  while  she  and  her  children  were  "  on  the  town."  If  the 
county  had  had  a  hospital  that  father  would  have  had  a  chance  for 
life.  At  least  he  could  have  saved  his  wife  the  burden  of  his  care, 
and  her  infection  might  have  been  avoided.    In  either  event,  if  he 


TUBERCULOSIS 


311 


had  lived,  or  if  his  wife  had  lived,  the  family  in  all  probability  would 
not  have  become  town  charges. 


YEAR 

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Fig.  98. — What  can  we  do  to  increase  this  encouraging  outlook? 

"  But  there  is  a  practical  taxpayer's  interest  also  in  this  story. 
If  the  county  had  had  a  hospital  the  effect  of  this  man's  illness  on 
the  tax  levy  would  have  been  as  follows : 


312  HOME  AND  COMMUNITY  HYGIENE 

One  year's  care  in  the  county  hospital,  at  $10  per  week $520 

Less  patient's  contribution  to  his  own  support 200 

Balance  paid  by  county $320 

^    "  There  was  no  hospital  whatever,  so  the  father  and  the  mother 
died,  and  this  is  the  way  the  public  account  stands : 

Care  of  father   Nothing 

Mother's  doctor's  bills  paid  by  town $50 

Support  of  family  during  mother's  illness 50 

Funeral   expenses   of  mother ! 25 

Care  of  2-year-old  child  in  orphan  asylum  for  twelve  years 1800 

Care  of  4-year-old  child  in  orphan  asylum  for  ten  years 1500 

Care  of  5-year-old  child  in  orphan  asylum  for  nine  years 1350 

Total    $4775 

"  In  other  words,  that  county  by  saving  $320,  the  theoretical 
cost  of  caring  for  the  father,  will  be  the  ultimate  loser  by  $4455, 
the  cost  of  caring  for  the  mother  and  her  orphans  minus  the  theo- 
retical cost  to  the  county  if  the  father  had  received  care." 

The  National  Committee  for  the  Prevention  of  Tuberculosis  has 
done  a  great  work  by  its  leadership  in  stimulating  practical  meas- 
ures to  control  that  disease ;  even  the  Christmas  seals  keep  the  prob- 
lem before  the  people  and  give  a  higher  sanction  to  local  movements 
that  is  distinctly  helpful.  But  local  societies  are  needed  partly  to 
secure  full  registration  of  this  disease  and  to  pick  out  the  otherwise 
unknown  cases,  and  to  provide  adequate  local  facilities  for  treat- 
ment, since  it  is  often  difficult  to  get  people  to  go  far  from  home 
(see  Chapter  XXV). 

After  the  community  has  become  interested  and  care  has  been 
made  possible  by  legislation  or  philanthropy,  there  are  still  three 
things  to  do.  (1)  The  tubercular  should  realize  his  responsibility 
toward  others,  and  conform  to  laws  of  safety  regarding  isolation,  if 
necessary;  more  often  his  duty  will  lie  in  the  painstaking  and 
annoying  details  regarding  the  care  of  discharges,  washing  of  hands, 
etc.  (Sputum  cups  should  be  burned;  and  if  handkerchiefs  are  not 
burned,  they  should  be  boiled  before  they  are  put  with  the  laundry. ) 
A  waiter  or  a  piece  worker  working  at  a  task  where  others  handle 
constantly  the  materials  he  has  handled  may  find  it  difficult  to  see 
that  it  is  his  duty  to  cease  such  work  and  find  othei7  employment. 
(2)    The  second  task  is  similar,  though  it  deals  with  those  not 


TUBERCULOSIS  313 

yet  definitely  proven  to  have  the  disease.  The  "  rather-not-know's " 
are  all  too  common.  They  are  needlessly  risking  their  own  lives, 
for  early  stages  are  more  easily  cured,  and  they  are  probably  injur- 
ing many  others.  It  is  a  selfish  attitude  and  should  be  recognized 
and  condemned  as  such.  Every  efliort  should  be  made  to  encourage 
and  secure  an  early  diagnosis  of  this  disease. 

(3)  The  third  task  consists  in  forming  in  the  well  certain  fixed 
habits  calculated  to  prevent  the  contraction  of  tuberculosis.  This, 
too,  is  not  easy,  for  usually  it  is  only  the  burnt  child  that  really 
dreads  the  fire.  But  the  well,  especially  those  with  a  predisposition 
toward  tuberculosis,  should  adopt  many  of  the  recommendations  for 
the  tubercular — so  alike  are  prevention  and  cure.  Contact  with  the 
infecting  organisms  should  be  avoided,  even  at  the  risk  of  appearing 
unsociable  or  "  fussy.''  Predisposing  factors  should  also  be  avoided : 
physical  strain,  such  as  overwork,  mental  strain  and  worry,  lack  of 
sleep,  improper  and  insufiicient  diets,  occupations  with  dusty  or 
irritating  atmospheres  or  demanding  cramped  chest  positions.  Each 
one  should  practice  the  hygienic  observances  known  to  be  aids  to 
health :  these  relate  mainly  to  bathing,  suitable  physical  exercise  or 
labor,  and  fresh  air  or,  preferably,  an  outdoor  life  (even  at  night), 
if  possible  without  overexposure  (Fig.  97). 

Inherited  Tuberculosis. — The  question  of  the  hereditary  char- 
acter of  tuberculosis  often  comes  up.  Tuberculosis  organisms  have 
never  been  seen  in  the  reproductive  cells.  Occasionally  the  disease 
may  be  transferred  before  birth,  however.  Whether  or  not  the  dis- 
ease is  acquired  before  or  after  birth  is  usually  a  minor  matter,  as 
the  opportunities  for  infection  after  birth  are  so  numerous  in  the 
homes  of  the  tubercular — especially  for  little  children.  It  is  hardly 
conceivable  that  a  tubercular  mother  could  avoid  the  frequent  trans- 
fer of  tuberculosis  bacteria  to  the  child  by  her  saliva-infected 
fingers  or  objects  that  they  have  touched,  spoons,  nipples,  etc.  To 
avoid  such  transfer  demands  more  thought  and  time  than  busy 
mothers  of  small  children  feel  they  can  give. 

Immunity. — The  immunity  that  seems  to  follow  earlier  cases  of 
tuberculosis  has  been  expressed  by  saying,  "  Only  the  tubercular 
are  immune  to  tuberculosis."  That  is  no  argument  for  subjecting 
children  to  tuberculosis,  for  "  latent  tuberculosis "  is  thought  re- 
sponsible for  the  majority  of  the  cases  developing  in  individuals 


314  HOME  AND  COMMUNITY  HYGIENE 

over  eighteen,  and  it  is  in  the  age  group  of  twenty  to  thirty  that  we 
find  our  highest  fatality  rate. 

Tuberculin. — Tuberculin  (G)  seems  less  valuable  in  diagnosing 
human  disease  than  bovine  tuberculosis.  If  the  characteristic  in- 
flammation and  fever  develop,  it  indicates  only  a  focus  of  infection 
— ^probably  an  old  or  encysted  one — not  necessarily  that  disease  is 
really  present.  Most  adults,  it  is  claimed,  give  positive  reactions, 
owing  to  childhood  infections.  Advanced  cases  may  fail  to  give  the 
reaction  entirely.  For  cows,  however,  the  tuberculin  test  is  consid- 
ered very  helpful — over  95  per  cent,  accurate. 

The  use  of  tuberculin  in  treating  tuberculosis  patients  has  been 
highly  advocated;  but  its  use  is  apparently  attended  by  very  real 
dangers,  and  should  not  be  attempted,  except  in  sanatoriums  or 
hospitals  with  trained  physicians  in  attendance.  Eepeated  doses  of 
such  foreign  substances  have  been  found  very  dangerous.  Its  ef- 
fects may  be  not  unlike  the  injurious  results  that  sometimes  attend 
a  second  dose  of  antitoxin  (see  Anaphylaxis). 

PROBLEMS 

1.  (a)  Make  a  list  of  rules  designed  to  prevent  a  tubercular  person 
from  transmitting  tuberculosis  to  his  family,  (b)  Make  a  similar  set  for  the 
family  living  with  the  patient. 

2.  How  many  tubercular  people  in  your  neighborhood  are  without  treat- 
ment or  medical  care? 

3.  How  many  of  the  charity  cases  in  your  locality  are  tubercular  or 
have  a  tubercular  history? 

4.  Make  a  set  of  rules  regarding  tuberculosis  for  distribution  in  the 
grammar  school  or  first  eight  grades. 

5.  Write  an  editorial  designed  to  influence  the  "solid  business  men"  of 
your  town  to  establish  a  tuberculosis  clinic  and  dispensary. 

6.  Send  to  your  State  department  of  health  for  their  pamphlet  on  pre- 
vention of  tuberculosis.  New  York,  New  Jersey,  Massachusetts  and  sev- 
eral other  Statesi  have  pamphlets  for  teachers  (or  for  school  children).  If 
your  State  has  none  prepare  one,  submitting  it  to  the  State  health  depart- 
ment, and  see  that  it  or  a  better  one  is  issued  by  the  State. 

7.  Read  An  Autobiography,  by  E.  L.  Trudeau;  what  do  you  consider  the 
most  interesting  contribution  of  this  sick  man  to  science  and  health? 

See  Reference  List  at  end  of  Appendix. 


CHAPTEE  XX 
INDUSTRIAL  AND  OCCUPATIONAL  HYGIENE 

OuK  occupations  may  affect  our  health  most  intimately.  These 
effects  are  of  five  main  types:  (1)  Those  favoring  the  transfer  of 
pathogenic  micro-organisms,  for  example,  hookworm  among  miners ; 
(2)  those  caused  by  irritating  chemicals  or  drugs,  such  as  lead  in 
the  du'st  freed  in  polishing  the  leaded  surfaces  of  pottery;  (3) 
those  causes  depressing  the  general  vitality,  such  as  intense  heat 
or  damp,  dark  surroundings;  (4)  fatigue,  which,  like  the  last  men- 
tioned type,  predisposes  to  disease  through  effect  on  general  vitality 
and  also  increases  liability  to  accidents;  and  (5)  accidents,  includ- 
ing those  of  the  specially  dangerous  occupations,  such  as  railroad- 
ing. An  abbreviated  list  of  the  best  known  irritating  factors  and 
the  conditions  under  which  they  usually  operate  is  given  below. 

It  must  be  recognized,  however,  that  the  diseases  and  deaths 
credited  to  a  given  occupation  or  condition  are  not  always  correct. 
Sick  people,  such  as  the  tubercular  and  men  who  break  down  in  one 
occupation,  often  drift  into  work  less  strenuous,  such  as  cigar  mak- 
ing or  mechanical  occupations.  This  raises  the  death  rates  in  cer- 
tain occupations ;  it  also  gives  a  false  impression  of  the  predisposing 
effect  of  those  occupations  to  certain  diseases  {e.g.,  tuberculosis). 

Value  of  Legislation. — Increases  in  the  accident  rate,  in  the 
illness  percentages,  and  in  the  earlier  death  ages  are  all  injurious 
economically  to  any  community.  These  industrial  conditions,  there- 
fore, cannot  be  left  to  the  employer.  There  are,  unfortunately,  a 
few  who  would  prefer  to  save  on  gas  masks,  safety  brakes,  fly-wheel 
or  belt  protectors,  or  lighting  or  ventilating  systems  at  the  expense 
of  human  life. 

Neither  are  the  employees  wholly  satisfactory  guardians  of  their 
own  health  and  safety.  Labor  organizations  have  done  much  to 
improve  their  own  economic  conditions,  and  occasionally  the  hy- 
gienic side  receives  attention,  but  very  often  legislative  and  other 
improvements  have  been  left  to  the  initiation  of  others.  This  is 
sometimes  due  to  ignorance,  to  seeing  the  present  large  and  the 
future  small,  to  a  lack  of  respect  for  other  human  life.    Ignorance 

315 


316 


HOME  AND  COMMUNITY  HYGIENE 


Cause  or  condition 


Occupations  or  workers 


Remarks 


Anthrax 

Hookworm.  . . 
Tuberculosis . . 

Wood  alcohol . 


Lead. 


White  phospho- 
rus 


Arsenic . 


Mercury . 


Carbon     mon- 
oxide 
Dust 


Excessive  moist- 
ure 


Workers  with  fur,  hides, 
bristles 

Miners;  if  non-disinfected 
excreta  containing  hook- 
worm be  left  exposed 

Any  dusty  occupation,  flour- 
making  to  stone-cutting 


Whien  substituted  for  ordi- 
nary alcohol,  as  in  dissolv- 
ing shellac  for  stiffening 
derby  hats 

Any  lead-dust  trade;  paint- 
ing, especially  where  pol- 
ishing is  involved;  lead 
glazing  on  pottery  and 
enamel  ware ;  making  white 
lead;  "tin  foil"  wrapping 

Match-making 


Makers  and  users  of  arsenic 
dyes,  in  clothing,  furniture, 
carpets,  cheap  wines  and 
candy;  and  furs  cured  by 
arsenic  method 

Making  of  thermometers, 
incandescent  lamps,  felts 
for  stiff  hats,  and  treating 
furs 

Workers  in  mines,  or  at  coke 
ovens,  blast-furnaces 

Workers  in  textiles  and  fi- 
bers, wood  flour,  tobacco, 
paper,  coal,  iron,  and  stone 

Laundries  and  textile  and 
twine  factories 


Occasionally  traced  even  to 
finished  shaving  brush  or 
furs  ready  to  wear 

50-80  per  cent,  infected  in  a 
few  States 

Pulmonary  tuberculosis,  with 
a  record  of  but  2  per  cent,  of 
non-dusty  occupations, 
reaches  8  per  cent,  for 
tobacco  dust,  14  per  cent, 
for  porcelain  dust,  and  34 
per  cent,  for  stone  dust 

Used  also  in  quick  drying 
paints,  insecticides,  etc. 


Paralysis,  especially  of  the 
hand,  is  common.  About  a 
dozen  other  industrial  poi- 
sons are  used  in  paints 


Not  used  in  "safety"  matches. 
Not  used  in  U.  S.  since  Bel- 
gian process  use  of  non- 
poisonous  form  of  phos- 
phorus 

Not  limited  to  green  dyes,  but 
dyes  of  practically  every 
ordinary  color 


Most  irritating  kinds  due  to 
(1)  liberated  chemicals  (as  in 
boxwood  for  rulers,  shuttles) 
or  (2)  to  sharp  edges  (iron 
and  stone  dust) 

Produces  skin  affections,  pre- 
disposes to  rheumatism  and 
respiratory  diseases  (?).  See 
p.  286,  also 


INDUSTRIAL  AND  OCCUPATIONAL  HYGIENE 


317 


Cause  or  condition 

Occupations  or  workers 

Remarks 

Noise      

Boiler  makers,  gunners  and 

caisson  workers 
AH  doing  "fine"  work,  as 

sewing,  weaving 

Standing,  bending  or  other 
uncomfortable  positions 

Lack  of  light. . .  . 

Continued  phys- 
ical discomfort 

Too     rapid    de- 
compression 

Eye  diseases,  extreme  fatigue, 
digestive  and  other  fatigue 
disturbances 

Flat  feet,  varicose  veins,  res- 
piration and  digestive  dis- 
turbances, spinal  curvature, 
etc. 

Affects  probably  90  per  cent, 
of  all  workers  (at  least 
slightly  ^) ;  fat  people  are 
especially  susceptible  (see 
p.  138)   - 

of  the  blinding  action  of  wood  alcohol  is  the  only  explanation  of  its 
use  by  workmen ;  the  present  good  explains  why  fathers  have  some- 
times placed  a  ten-year-old  boy  in  the  mines,  or  a  five-year-old 
daughter  in  the  cotton  mills;  and  the  low  value  of  human  life  is 
illustrated  by  the  naive  statement  of  a  foreigner  who,  when  asked 
why  he  left  his  wife  without  medical  attendance  "during  a  serious 
disease,  but  called  in  a  veterinarian  to  doctor  his  cow,  said :  "  I'd 
have  to  buy  another  cow." 

How  little  labor  is  doing  and  how  much  more  labor  might  do  for 
itself  is  shown  by  the  fact  that  the  American  Labor  Year  Book  for 
1917-18  mentions  health  but  three  times  in  the  index,  and  the 
matter  referred  to  covers  less  than  seven  pages. 

Workmen's  compensation  laws  and  employers'  liability  laws 
have  benefited  both  the  individual  and  the  community  directly  and 
indirectly.  Employers  find  it  cheaper  to  install  better  ventilation, 
protective  devices,  etc.,  than  to  pay  compensation  awards;  and  the 
individual  and  his  family  gain  in  health,  and  by  the  extension  of 
his  productive  years.  The  community  benefits  in  those  same  eco- 
nomic ways,  and  also  in  ways  less  easily  measured,  such  as  the 
higher  mental  and  moral  tone  of  men  no  longer  viewed  as  mere 
material  or  animals  to  be  exploited. 

^  Kober  and  Hanson  show,  however,  that  if  the  percentage  of  such  effects 
is  based  on  the  number  of  opportunities,  that  is,  on  the  number  of  decom- 
pressions, the  percentage  is  less  than  1  per  cent. 


318  HOME  AND  COMMUNITY  HYGIENE 

Factory  inspection  is  the  usual  method  of  securing  the  execution 
of  such  laws.  Public  opinion  has  often  been  a  wonderful  factor  in 
enforcing  as  well  as  in  framing  these  laws,  and  a  stirring  news- 
paper or  magazine  article  has  often  been  the  main  force  at  work. 
J  Many  workmen  are  very  careless,  refusing  to  take  proper  pre- 
cautions (gas  masks,  rubber  gloves,  frequent  hand  washing,  espe- 
cially before  meals),  or  taking  undue  risks  in  dangerous  places  or 
around  unprotected  machinery.  (Studies  of  several  hundred  acci- 
dents showed  the  workmen  directly  responsible  in  over  half  of  the 
cases.) 

Fatigue  studies  with  regard  to  the  working  hours  per  week  and 
per  day  and  to  the  number  of  breaks  or  intermissions  all  tend  to 
show  an  increased  output  per  hour  when  the  worker  works  as  he 
would  naturally.  Comprehensive  studies  of  fatigue  and  efficiency 
made  here  and  abroad,  both  before  and  during  the  war,  have  shown 
in  private  and  government  industries  a  lessening  of  efficiency  with 
prolonged  work  periods.  There  are  indications  that  laborers  of  a 
certain  type  (digging)  could  work  ten  hours  a  day  without  ma- 
terially lessening  their  hourly  output,  or  affecting  their  health. 
But  almost  all  types  of  work  involve  mental  strain  and  skill  demand- 
ing alertness,  keenness  of  vision,  deftness  of  touch,  etc.  Factories 
working  eight  hours  instead  of  ten  per  day,  forty-four  instead  of 
fifty-four  hours  per  week,  have  found  both  their  hourly  and  the 
weekly  output  higher  for  each  worker.  In  emergencies,  the  in- 
creased time  can  be  used  to  advantage,  but  life  should  not  be 
planned  on  that  basis.  Ordinary  house  work,  with  its  long  hours, 
demands  some  readjustment.  Though  there  are  often  intervals 
when  one  can  relax  and  go  on  refreshed,  these  may  be  nullified  by 
the  constant  and  insistent  demands  of  children  and  invalids.  Many 
homes — as  far  as  man-saving  power  is  concerned — are  conducted 
along  inefficient  lines  not  tolerated  in  ordinary  factories.  The  im- 
portance of  happy,  well  housekeepers  and  home-makers  to  a  com- 
munity needs  but  to  be  mentioned  to  be  realized. 

How  much  there  is  to  do  is  shown  by  the  recent  army  draft,  in 
which,  according  to  the  statement  of  a  large  labor  organization, 
over  60  per  cent,  of  factory  youth  are  exempted  for  physical  rea- 
sons. If  ordinary  factory  conditions  have  such  a  record,  what  would 
be  the  record  of  occupations  such  as  those  discussed  in  this  chapter  ? 


INDUSTRIAL  AND  OCCUPATIONAL  HYGIENE  319 

PROBLEMS 

1.  Make  fatigue  curves  of  some  daily  or  monotonous  duty,  e.g.,  iron- 
ing, with  and  without  a  relaxation  interval  (5  minutes)  every  hour  or  every 
half  hour. 

2.  Does  your  "head  save  your  heels"  ?  Show  how  several  of  the  homely 
tasks  could  be  more  efficiently  done  by  such  a  change  in  method? 

3.  A  clever  objection  to  the  above  theory  was  made  by  someone  who 
said  that  her  heels  were  meant  to  serve  her  head,  and  there  was  no  reason 
for  tiring  her  brain  out  in  planning  to  save  steps.  Can  you  give  a  good 
illustration  for  this  side  of  the  argmnent? 

4.  Which  of  these  conditions  in  the  table  on  page  316  can  be  improved 
by  collecting  hoods  over  the  individual  machines?  By  individual  masks? 
By  better  general  ventilation  ?  By  shorter  hours  ?  By  rest  intervals  ?  Find 
one  instance  in  which  another  remedy  seems  necessary. 

5.  What  are  the  child-labor  laws  for  your  State?  What  relation  have 
they  to  this  question? 

6.  Among  the  important  problems  not  touched  in  this  chapter  are  the 
housing  problems  of  workers  in  such  temporary  or  emergency  conditions 
as  railroad  or  bridge  construction,  and  munition  work.  Give  necessary 
rules  of  sanitation  for  one  such  situation. 

8ee  Reference  List  at  end  of  Appendix. 


CHAPTEE  XXI 
MENTAL  HYGIENE 

Mental  defects  are  so  different  in  degree  as  well  as  in  kind  that 
one  brief  chapter  cannot  give  a  detailed  description  of  the  types, 
nor  an  adequate  discussion  of  the  methods  of  treating  or  preventing 
such  mental  defects.  Those  having  to  face  such  problems  must 
realize  that  this  chapter  can  do  little  more  than  present  the  situation. 

Types  of  Mental  Diseases  and  Defects. — Mental  abnormali- 
ties are  commonly  grouped  as  insane,  feeble-minded,  criminalistic, 
epileptic,  or  inebriate.  Most  of  these  classes  can  be  again  divided, 
in  degree  if  not  in  type.  For  example,  the  largest  group,  the  feeble- 
minded, may  be  sub-divided  into  the  idiots,  who  never  progress  be- 
yond the  two-year  stage;  the  imbeciles,  whose  development  stops 
with  the  four-year  stage;  the  morons,  never  developing  beyond  an 
average  twelve-year-old:  and  a  fourth  class  grading  almost  in- 
sensibly into  the  normal  class.  It  is  in  this  fourth  class  that  we 
find  the  generally  irresponsible,  the  ne'er-do-wells;  it  furnishes 
more  of  the  criminals,  degenerates,  paupers,  and  drug  and  alcohol 
fiends  than  any  other  class  of  society.  Here,  too,  belong  "  the  spend- 
thrifts, the  niggards,  the  cranks,  the  visionaries,  the  malicious  gos- 
sips, the  fops,  and  empty  people  in  general." 

Causes  of  Mental  Defects. — ^The  causes  of  the  mental  defects 
which  often  appear  or  begin  in  childhood  include  such  generally 
recognized  causes  as  adenoids,  malnutrition,  defects  in  vision  and 
hearing,  and  harmful  home  or  environmental  influences.  Nerve 
fatigue  (neurasthenia)  and  St.  Vitus's  dance  (chorea)  may  lead 
to  fixed  abnormalities  such  as  nervous  twitchings,  morbid  ideas, 
undue  sensitiveness,  self-consciousness,  etc.  Any  "habit  twitch- 
ings," whether  due  to  imitation  (for  such  habits  as  twitching  and 
stammering  may  spread  rapidly  through  a  classroom),  eye  defects, 
adenoids,  or  nerve  fatigue  should  have  immediate  attention.  Nerve 
fatigue  has  as  one  of  its  earliest  symptoms  increased  excitability  or 
"brightness,"  and  this  often  leads  to  an  exaggeration  of  this  con- 
dition by  continuing  or  increasing  the  strain  in  such  "  bright "  chil- 
dren. Mental  defects  in  older  children  are  sometimes  aggravated  by 
320 


MENTAL  HYGIENE  321 

those  who  do  not  realize  that  forgetfulness,  loss  of  interest  in  work 
and  play,  carelessness  in  dress  or  personal  habits,  etc.,  are  often 
transitory  phases  of  the  adolescent  period. 

Disease  as  a  Cause. — Disease  is  an  important  factor  in  mental 
deficiency.  Rosenau  states  that  pellagra  (G)  is  "responsible  for 
thousands  of  cases  of  mental  disease  in  the  localities  in  which  it  is 
prevalent."  Syphilis  is  accepted  as  "  the  essential  cause  "  of  general 
paresis  (G),  which  is  responsible  for  about  13  per  cent,  of  all  first 
admissions  to  hospitals  for  the  insane ;  recovery  rarely,  if  ever,  occurs 
among  the  syphilitic  insane.  The  fact  that  syphilis  may  be  trans- 
mitted even  to  the  "  third  and  fourth  generation "  indicates  its 
importance  as  a  cause  of  mental  deficiency.  Typhoid  fever,  influ- 
enza, malaria,  blood  poisoning,  cause  a  small  number  of  the  mentally 
defective ;  these  effects  are  mainly  due  to  brain  hemorrhages  or  local 
meningitis  following  or  attending  such  diseases,  or  even  measles  or 
scarlet  fever. 

Other  Causes. — Head  injuries  cause  a  small  number  of  mental 
defects,  especially  insanity.  These  are  apparently  more  numerous 
in  people  with  predisposing  habits,  e.g.,  alcoholics.  Purely  mental 
conditions,  such  as  worry,  pain,  fear,  and  grief,  are  often  accepted  as 
causes.  It  may  well  be  that  the  strength  or  the  lack  of  control  of 
such  emotions  is  itself  rather  an  indication  of  the  degree  of  mental 
poise  or  balance.  Unable  to  make  the  normal  adaptations,  the  indi- 
vidual seeks  refuge  by  avoiding  his  kind,  or  consoles  or  excuses  him- 
self by  imagining  the  dead  still  live ;  that  he  has  supreme  power  to 
change  all  things;  that  his  companions  are  all  conspiring  against 
him,  etc.  Such  obsessions  often  develop  late  in  life,  when  the  ad- 
justments are  greatly  increased  in  number,  variety,  and  importance. 

Alcoholics  and  drug  addicts  are  probably  mentally  weak  or  irre- 
sponsible primarily  and  alcoholics  or  "drug  fiends"  secondarily. 
Goddard  says  alcoholism  is  itself  only  a  symptom,  occurring  where 
some  form  of  neurotic  taint  exists,  especially  feeble-mindedness. 
Such  habits  and  a  weak  intellect  make  "  a  vicious  circle,"  of  course, 
and  mental  cures  cannot  be  permanently  effected,  if  such  unde- 
sirable habits  are  continued ;  and  even  moderate  drinking  has  been 
shown  by  many  types  of  experiments  to  impair  mental  efficiency: 
e.g.,  memory  tests,  typewriter  speed  and  accuracy,  and  typesetting. 
Forel  makes  a  more  positive  statement,  claiming  that  alcohol  is  the 


322  HOME  AND  COMMUNITY  HYGIENE 

only  cause  that  can  be  proved  by  statistics  to  give  a  direct  new  taint 
of  mental  deficiency. 

Drugs  apparently  play  a  minor  and,  like  alcohol,  a  secondary 
i-61e.  But  one  per  cent,  of  hospital  and  institution  admissions  are 
attributed  to  drugs.  This  present  low  rate  is  partly  due  to  the  de- 
creased sale  of  injurious  drugs  whether  sold  as  such  or  concealed  in 
patent  medicines. 

Preventive  Measures. — Preventive  measures  may  be  discussed 
from  the  standpoint  of  the  individual  who  is  mentally  defective,  or 
with  the  view  to  decreasing  the  alarming  numbers  of  mental  defec- 
tives reported  all  through  our  country. 

Individual  Treatment. — Individuals  who  are  known  or  sus- 
pected to  be  mentally  defective  should  be  examined  thoroughly  by 
competent  physicians  with  the  purpose  of  determining  the  degree 
of  deficiency,  and,  if  possible,  its  cause.  Predisposing  or  causal 
hindrances  should  be  removed  as  promptly  as  the  physical  and  ner- 
vous state  of  the  individual  allows.  Operations  for  adenoids,  cor- 
rect glasses,  and  ear  treatments  have  had  wonderful  effects  upon  a 
child's  attitude  and  his  mental  powers.  Sometimes  previous  me- 
chanical injury  may  make  trephining  (G)  or  a  similar  operation 
necessary  to  remove  brain  pressure  and  restore  mental  ability. 

Having  removed  as  completely  as  possible  the  physical  causes, 
attention  should  be  given  to  the  other  factors  affecting  the  indi- 
vidual. Defective  children  should  be  cared  for  in  a  special  class. 
This  is  desirable  from  the  point  of  view  of  the  normal  children  as 
well  as  the  defective.  Defectives  in  a  classroom  tend  to  lower  the 
teaching  standards,  and  unfortunate  imitation  habits  are  often 
acquired  by  the  normal  children.  Such  special  classes  for  defec- 
tives offers  opportunities  for  "  developing  their  modest  abilities,"  for 
forming  good  habits  of  personal  care,  of  work  and  social  inter- 
course, and  for  escaping  the  alternatives  of  dependency  and 
delinquency. 

Conscientious,  intelligent  work  with  the  mentally  deficient  has 
established  that  many  types  of  insanity  are  incurable.  Among  the 
feeble-minded  there  are  many  who  do  not  progress  beyond  the  imi- 
tative or  habit  stages.  There  are  many  others  not  usually  classed 
as  feeble-minded  who  can  never  be  trusted  to  meet  a  new  situation 
successfully,  who  can  never  be  sure  of  standing  firm  on  any  moral 
issue,  who  can  never  see  a  situation  as  a  whole,  or  in  its  relation  to 


MENTAL  HYGIENE  323 

other  people  or  to  the  future.  For  all  such,  the  training  must  of 
necessity  be  adapted  to  the  individual's  probable  environment,  or  a 
favorable  environment  must  be  selected  in  which  the  individual  will 
be  most  comfortable,  and  in  which,  if  possible,  he  can  become  a 
contributing  member  of  society. 

Where  the  abnormality  is  due  to  shock,  uncontrollable  fear,  etc., 
help  is  sometimes  possible  through  "  mental  treatment."  Fears 
may  be  dispelled  and  confidence  may  be  restored  by  such  treatment. 
There  is  grave  danger,  however,  in  some  of  the  types  of  treatment 
now  being  advocated,  especially  for  adolescents,  that  too  great  em- 
phasis upon  self  may  develop  a  degree  of  introspection  itself  harm- 
ful, especially  at  that  age.  Recourse  should  be  made  first  of  all  to 
those  treatments  that  tend  to  make  such  individuals  forget  them- 
selves. It  is  the  outside  world — including  other  people — which 
should  be  emphasized,  not  the  ego,  which  looms  too  large  already. 

Cases  of  St.  Vitus's  dance  and  nerve-fatigue  should  be  with- 
drawn from  school  or  protected  from  other  exciting  environments. 
A  quiet,  healthful  routine  should  be  substituted ;  much  helpful  treat- 
ment is  destroyed  by  petty  friction  at  home  or  by  continual  discus- 
sion of  the  child,  his  symptoms,  and  his  sensitiveness,  thus  increas- 
ing often  the  very  conditions  the  parents  really  want  to  cure. 

Physical  and  nervous  strain  should  be  avoided  for  all  on  the 
borderland  of  mental  instability,  or  with  predisposing  inheritances 
or  histories.  Keedless  exposure  to  diseases  should  be  avoided,  espe- 
cially in  individuals  with  delicately  balanced  nervous  constitutions, 
or  whose  illnesses  are  attended  by  delirium.  Chronic  or  slowly  de- 
veloping disease,  such  as  malaria  and  syphilis,  should  be  treated 
promptly,  so  that  the  insidious  poisons  of  such  diseases  shall  not  be 
continually  accumulating  in  the  system. 

Census  of  Mental  Defectives. — ^The  following  figures,  based 
mainly  on  records  of  hospitals  and  similar  institutions,  show  an 
alarming  increase  in  mental  defectives.  This  increase  is  real, 
though  not  so  great  as  the  figures  indicate  because  of  three  things : 
(1)  the  better  diagnosis  methods  of  to-day;  (2)  a  growing  realiza- 
tion that  mental  diseases  are  diseases,  and  need  expert  treatment 
which  can  rarely  be  provided  at  home;  and  (3)  the  great  change  in 
such  institutions,  which  are  no  longer  prisons,  but  homes  where  the 
aim  is  to  keep  the  patient  happy  and  contented,  and  where  the 
treatment  is  corrective  rather  than  repressive. 


324  HOME  AND  COMMUNITY  HYGIENE 

However,  the  question  is  not  the  faulty  lower  record  of  the 
past  decades,  but  the  high  proportion  of  mental  deficients  known  to 
exist  to-day.  A  report  of  the  jSTational  Committee  for  Mental  Hy- 
giene states  that  January  1,  1917,  there  were  in  the  United  States 
"'in  the  571  institutions  for  feeble-minded,  insane,  etc.,  over  37,000 
feeble-minded,  nearly  11,000  epileptics,  nearly  5000  inebriates,  and 
over  231,000  insane,  a  total  of  over  287,000.  This  means  nearly 
three  people  for  every  thousand  inhabitants.  This  does  not  include 
all  the  smaller  private  institutions,  and,  of  course,  takes  no  record 
of  many  feeble-minded  cared  for  in  their  own  homes.  This  num- 
ber of  defectives  exceeds  the  number  of  students  registered  in  all 
the  colleges  and  universities  in  the  whole  country ! 

The  average  cost  of  supporting  such  incapables  is  put  at  $175  a 
year  per  person.  This  does  not  include  the  economic  loss  to  the 
country  represented  in  each  unproductive  citizen,  nor  the  enormous 
private  or  famil}''  expenditures.  It  makes  the  cost  more  real,  per- 
haps, if  we  state  that  Massachusetts  has  for  such  cases  one  hospital 
bed  for  every  1400  of  its  population,  and  in  recent  years  has  spent 
one-sixth  of  the  total  State  appropriations  for  the  insane  and 
feeble-minded.  In  1913,  in  jSTew  York  State  one-quarter  of  the 
total  State  appropriations  went  for  the  same  purpose.  It  is  not  too 
much  to  say  that  this  is  not  the  proper  condition  of  affairs.  With 
so  many  wards  of  normal  mentality  who  lack  food,  proper  shelter, 
education,  and  healthful  and  improving  amusement  and  all  the  finer, 
higher  opportunities  that  come  with  leisure  and  education,  no  State 
can  afford  to  spend  one  dollar  of  every  four  on  this  minority  of  its 
population — on  individuals  who  often  cannot  appreciate  the  com- 
fort thus  provided  and  who  can  never  contribute  to  the  welfare  of 
others. 

Clearly,  these  unfortunates  must  be  cared  for  humanely.  But 
something  should  be  done  to  check  the  constant  yearly  additions  to 
these  classes  of  dependents.  About  30,000  admissions  are  now  made 
yearly  to  the  571  registered  public  and  private  institutions  in  the 
United  States.  In  some  States  the  feeble-minded  are  apparently 
increasing  twice  as  fast  as  the  population.  What  can  be  done  to 
decrease  this  alarming  condition  of  affairs? 

Immigrant  Control. — Immigrants  provide  an  undue  propor- 
tion of  the  insane  and  feeble-minded.  Hundreds  are  deported  dur- 
ing their  first  year  of  residence  for  mental  diseases  due  to  causes 


MENTAL  HYGIENE  325 

antedating  their  arrival  here.  Immigrants  are  represented  in  our 
hospitals  in  higher  proportions  than  they  bear  to  our  population. 
They  usually  have  large  families,  and  so  directly  and  indirectly, 
through  the  dependence  and  inherited  weaknesses  of  their  children, 
they  increase  the  numbers  of  the  mentally  deficient. 

We  have  no  definite  provision  for  ascertaining  that  incoming 
people  are  free  from  mental  disease.  Adequate  standards  must 
be  adopted  and  enforced.  When  it  is  put  plainly  as  "a  ques- 
tion whether  we  or  the  foreign  steamship  agents  shall  select  the 
parents  of  future  generations  of  Americans,"  there  can  be  but  one 
answer. 

Any  method  dealing  adequately  with  the  problems  of  mental  de- 
ficiency must  recognize  that  feeble-mindedness  and  insanity  may  be 
inherited.  Several  investigations,  each  including  several  hundred 
patients,  showed  family  histories  of  mental  disease  in  more  than 
half  the  feeble-minded  and  insane;  the  proportion  of  family  his- 
tories with  mental  disease  is  but  3  to  8  per  cent,  in  normal  indi- 
viduals. It  is  not  easy  to  trace  the  ancestry  of  the  illegitimate  and 
dependent  offspring  unfortunately  so  common  among  the  descend- 
ants of  the  feeble-minded;  were  they  more  complete,  consid- 
erably more  than  half  might  be  found  with  histories  of  mental 
diseases. 

Scientific  investigations  have  enabled  students  in  this  field  to 
predict  with  considerable  accuracy  the  degree  in  which  certain  de- 
fects will  be  inherited.  Certain  defects  tend  to  disappear  when 
their  victims  are  mated  with  normal  individuals;  others  may  be 
confidently  expected  in  the  first  generation.  Marriage  of  two  people 
apparently  normal,  but  who  have  a  similar  family  taint,  may  lead 
to  abnormal  offspring.  Marriage  of  people  closely  related  by  blood 
often  brings  to  the  surface  unsuspected  defects,  such  as  blindness, 
deaf -mutism,  idiocy,  insanity,  and  intellectual  dullness.  It  is  essen- 
tial that  an  individual  with  a  questionable  family  history  should 
consult  a  competent  specialist  before  deciding  to  rear  a  family.  His 
decision  may  allay  secret  fears  that  would  otherwise  haunt  the  indi- 
vidual for  years.  Even  if  marriage  is  forbidden,  the  disappoint- 
ment or  grief  cannot  compare  with  the  suffering  and  responsibilities 
associated  with  the  problems  of  mentally  diseased  offspring.  In 
such  cases,  the  individual  must  face  the  issue  squarely,  and  realize 
that  it  is  not  bravery  to  "  take  the  risk,"  but  that  he  may  be 


326  HOME  AND  COMMUNITY  HYGIENE 

responsible  for  years  of  suffering  in  tlie  lives  of  his  offspring,  and 
inflict  upon  his  community  incalculable  harm. 

This  is  illustrated  by  the  well-known  history  of  the  Jukes  family, 
which  so  far  has  cost  New  York  State  more  than  125  million  dol- 
^lars.  To  a  lazy  and  irresponsible  fisherman  born  in  1720  are 
traced  over  1200  persons  in  five  generations,  including  about  200 
who  married  into  the  family.  Of  these,  about  300  died  in  in- 
fancy, 310  were  professional  paupers,  130  were  convicted  criminals, 
60  were  habitual  thieves,  7  were  murderers,  440  were  wrecked  by 
venereal  disease,  and  more  than  half  the  women  led  immoral  lives. 
Not  one  had  a  common  school  education,  and  but  20  learned  a  trade 
(10  of  these  learning  it  in  prison). 

The  damage  done  by  a  taint  on  one  side  only  is  illustrated  by 
the  Kallikak  family  described  by  Goddard.  The  Kallikak  history 
includes  two  branches  started  by  one  man  who  married  a  Quakeress 
and  so  started  a  line  of  descendants,  which  now  totals  496  members, 
and  contains  only  responsible  worthy  citizens  without  any  feeble- 
minded, criminal,  or  even  ne'er-do-wells,  except  two  abnormal  indi- 
viduals whose  abnormality  can  be  shown  to  be  due  to  outside  strains 
brought  in  by  intermarriage.  This  same  Kallikak  ancestor  before 
marrying  the  Quakeress  had  an  illegitimate  child;  its  mother  was 
a  feeble-minded  girl.  The  total  descendants  of  this  feeble-minded 
line  now  number  480  individuals,  many  of  whom  cannot  be  traced. 
Among  those  traced  are  but  46  normal  individuals;  82  died  in  in- 
fancy, 36  were  illegitimate,  24  confirmed  alcoholics,  3  epileptics,  34 
were  criminals  or  criminalistic,  and  143  were  feeble-minded. 

In  the  Zero  family  we  have  a  balance  to  the  lesson  in  the 
Kallikak  family,  for  a  Swiss  family  having  two  lines  of  highly  re- 
spected descendants  produced  by  intermarriage  a  branch  beginning 
with  a  man  thereby  tainted  with  insanity.  He  married  a  roving 
Italian  vagrant  of  vicious  character;  and  their  son  married  a  Ger- 
man vagabond.  All  their  descendants  were  vagabonds,  thieves, 
inebriates,  or  showed  mental,  moral,  and  physical  defects. 

Remedies. — It  is  evident  that  only  the  responsible  will  be  re- 
strained from  marriage  by  the  probability  of  the  transfer  of  mental 
defects.  The  irresponsible  are  not  restrained  by  such  arguments. 
For  such,  various  recommendations  have  been  made:  segregation, 
sterilization,  and  legislation  preventing  marriage  of  those  who  can- 
not obtain  a  medical  license.    The  first  two  are  not  practicable  with- 


MENTAL  HYGIENE  327 

out  a  strong  supporting  public  opinion.  Segregation  cannot  be  ap- 
plied to  all  unless  mental  deficiency  is  made  a  notifiable  disease.^ 
Examining  and  advisory  clinics  are  too  often  provided  only  for 
those  who  come  before  juvenile  and  criminal  courts.  Segregation 
to  be  adequate  must  be  absolute  and  so  forbid  leave,  home  visits,  etc. 
Surgical  sterilization  is  now  provided  for  in  eleven  States,  and 
while  it  is  both  harmless  and  efficient,  it  has  not  been  found  practi- 
cable. Legislation  demanding  a  medical  license  for  marriage  in- 
creases somewhat  the  illegitimacy  rate.  However,  it  probably 
prevents  many  an  unsafe  marriage,  and  it  calls  attention  to  the 
whole  problem. 

The  only  other  remedy  is  in  education  and  a  development  of  a 
sense  of  personal  responsibility.  A  country  that  in  seven  years  has 
an  increase  of  79  per  cent,  of  its  feeble-minded  population  and  of 
24  per  cent,  in  its  insane  population  must  find  a  solution  to  this 
problem. 

PROBLEMS 

1.  What  should  be  the  attitude  of  parents  toward  the  training  or  edu- 
cation of  an  abnormal  child? 

2.  In  the  ordinary  community  what  effective  aid  may  we  expect  from 
the  doctor  in  helping  solve  mental  hygiene  problems?  From  the  teacher? 
The  school  nurse?     From  the  minister?     The  editor?    The  librarian? 

3.  In  some  communities  it  has  been  customary  to  encourage  the  mar- 
riage of  young  feeble-minded  pauper  women  in  order  to  free  the  taxpayer 
of  their  support?     Criticise  this  as  an  economic  measure. 

4.  What  institutions  in  your  State  receive  the  insane?  Those  not  able 
to  support  themselves?  Those  wishing  or  able  to  pay  for  support?  The 
criminal  insane?     The  feeble-minded?     The  epileptic? 

5.  What  per  cent,  of  your  State  money  goes  to  support  the  classes  men- 
tioned in  Problem  4? 

See  Reference  List  at  end  of  Appendix. 

^Mental  deficiency  should  be  included  in  the  notifiable  diseases.  New 
Jersey  is  apparently  a  pioneer  in  this  respect.  We  should  in  that  way  have 
a  complete  register  of  such  diseases  instead  of  a  register  including  only 
those  in  institutions  and  hospitals. 


CHAPTER  XXII 

MILITARY  HYGIENE 

Hygienic  Effects  of  War. — 'War,  especially  the  recent  war, 
has  two  distinct  and  opposite  effects  upon  hygiene,  injurious  and 
beneficial.  The  injurious  effects  are  serious  ones;  but  when  war  is 
waged  it  is  sensible  to  make  the  most  of  any  benefits  that  may  help 
counteract  such  injurious  effects.  The  beneficial  effects  we  can  at 
present  see  are,  therefore,  as  follows :  War  emphasizes  and  makes 
more  or  less  familiar  the  important  hygienic  advances  and  discov- 
eries made  in  the  time  of  peace,  such  as  the  control  of  typhoid  and 
venereal  diseases.  Even  those  with  the  very  lowest  sense  of  self-re- 
spect and  personal  responsibility  can  never  wholly  forget  or  ignore 
the  military  standards  set  by  the  federal  government  in  such  mat- 
ters as  care  of  the  teeth,  personal  cleanliness,  safe  drinking  waters, 
abstinence  from  alcohol,  care  of  wounds,  disposal  of  waste,  dan- 
gers from  flies  and  other  insect  carriers  of  disease.  Lectures,  edu- 
cational literature,  moving  pictures,  and  enforced  observance  of 
hygienic  habits  all  drive  these  home  to  our  soldiers  in  camp.  The 
experiences  of  the  absent  are  of  the  keenest  interest  to  the  people 
left  at  home ;  the  members  of  girl  and  boy  scout  organizations  and 
the  people  as  a  whole  benefit  proportionately.  The  benefit  to  the  in- 
dividual must  be  recognized  also.  Wood  says  that  the  training 
capip  records  of  even  those  men  who  have  been  accepted  as  fit 
"  show  that  in  multitudes  of  cases,  and  within  six  months  after  the 
beginning  of  training,  the  improvement  in  health,  in  vitality,  in 
physical  and  general  efficiency  has  been  almost  incredible." 

The  injurious  effects  are:  (1)  The  demands  of  the  sick  and 
wounded  tend  to  deflect  money,  nurses,  and  even  protective  legisla- 
tion from  the  coming  generation.  (2)  The  horrors  of  war  tend  to 
blunt  our  sensibilities  to  the  still  present  horrors  of  peace,  such  as 
infant  mortalit}^,  child  labor,  child  delinquency,  and  industrial  and 
traffic  accidents.  (3)  There  is  also  a  let-up  in  the  battle  against 
insects  and  other  pests  that  directly  (carrying  disease)  or  indirectly 
(by  economic  relations)  affect  man's  welfare.  (4)  And  no  one 
denies  the  effect  upon  the  health  of  the  coming  generations  when 
328 


MILITARY  HYGIENE  329 

"the  beBt  are  killed"  and  "the  worst  are  left  at  home/'  even 
though  the  defects  that  lead  to  exemption  are  not  always  trans- 
missible. (5)  We  must  also  include  after- war  conditions:  though 
our  government  is  already  preparing  to  meet  the  problems  of  the 
crippled  and  otherwise  incompletely  self-supporting. 

Methods  of  Selection. — The  method  of  selecting  men  for  our 
military  forces  and  the  care  of  the  men  in  the  army  and  navy  are 
all  designed  to  minimize  the  evils  of  war.  We  will  discuss  briefly 
the  principles  determining  the  selection  of  men  for  the  army/  and 
then,  later,  the  methods  of  caring  for  them. 

At  all  times  the  regulations  are  designed  to  safeguard  the  wel- 
fare of  the  men,  for  no  army  is  eflEicient  if  made  up  of  sick  men. 
But,  in  times  of  great  stress  or  emergency,  these  principles  may  have 
to  be  modified,  or  may  even  give  way.  For  example,  at  the  outbreak 
of  the  war  the  tocsin  sounded  in  the  little  town  of  Poligny  at  half- 
past  four  one  afternoon  to  announce  the  coming  of  the  enemy. 
The  next  morning  at  nine  475  men  marched  away  from  that  little 
town  of  1145  people !  There  was  no  time  to  determine  age  limits 
or  physical  witness.  What  wonder  that  tuberculosis  has  spread 
rapidly  among  such  hastily  selected  armies  ? 

When  time  allows,  the  selection  of  soldiers  should  be  carefully 
made.  Every  sick  soldier  is  a  soldier  less ;  he  is  also  a  dead  weight 
upon  his  army  and  his  country ;  for  he  requires  the  services  of  able- 
bodied  men,  he  may  be  a  focus  of  infection,  he  is  a  distinct  money 
loss  (previous  training,  feeding,  hospital  care),  and  he  may  be  a 
pensioner  of  his  government  for  many  years. 

Age. — Age  is  an  important  factor  in  selection.  If  too  young, 
the  applicant's  bones  have  not  reached  their  final  hardness  and  the 
joints  are  not  fully  developed  (hence  greater  fatigue  in  the  hollow 
of  the  back,  lack  of  proper  support  of  weight  by  pelvic  bones). 
His  muscles  lack  endurance,  and  in  long  marches  it  is  the  boys  who 
"  fill  the  hospitals  and  encumber  the  roadside."  The  chest  has  not 
reached  its  full  capacity,  and  heavy  equipment  or  other  strain  may 
cause  displacement  or  other  injuries  to  the  heart  and  lungs.  Our 
upper  limit  for  drafted  men  is  thirty-one  years,  though  older  men 
are  in  the  service,  and  older  ones  in  good  health  may  volunteer 
their  services,  especially  in  allied  departments :  shipbuilding,  motor 

^  Army,  as  used  throughout,  for  the  sake  of  brevity,  includes  the 
whole  military  force — navy  as  well  as  army. 


330  HOME  AND  COMMUNITY  HYGIENE 

construction,  etc.  The  "  veterans  "  of  Napoleon  were  twenty-six  to 
twenty-eight  years  old,  and  his  "  old  guard  "  were  twenty-eight  to 
twenty-nine.  Much  older  men  may  have  muscles  that  are  too  "  set/' 
depending  partly  on  how  restricted  their  previous  work  has  been; 
they  are  more  often  affected  with  the  nutritional  and  organic  dis- 
eases of  middle  age;  heart  affections,  hernia,  kidney  diseases,  etc., 
are  common  disqualifications  which  need  no  explanation. 

Other  Physical  Qualifications. — Height  is  also  important. 
The  limits  are  usually  sixty-four  to  seventy-two  inches ;  uniformity 
is  quite  desirable  in  all  men  who  march,  because  of  the  different 
step  length.  Weight  is  important.  While  the  lower  limit  is  usually 
128  pounds,  120  may  be  accepted,  if  the  flesh  is  firm  and  the  ap- 
plicant is  evidently  vigorous  and  active.  The  cavalry  upper  limit 
(164)  is  lower,  naturally,  than  that  for  other  departments  (190). 
Weight  and  height  must,  of  course,  be  considered  together. 

To  Napoleon  we  credit  the  saying  that  "battles  are  won  with 
legs  rather  than  arms."  Motor  trucks  have  not  lessened  the  im- 
portance of  human  locomotion,  and  "  getting  there  first "  is  still  an 
important  element  of  success.  Feet  are,  therefore,  carefully  in- 
spected, and  anything  which  reduces  the  strength  or  springiness  of 
the  foot  materially  is  cause  for  rejection  (flat  foot,  abnormal  toes 
and  loss  of  important  toes).  Recently,  the  hip  breadth  has  been 
shown  to  be  even  more  important.  The  applicant  should  have  suffi- 
cient fingers  to  manage  his  firearms,  etc. 

Teeth  are  most  important;  the  minimum  is  usually  four  pairs 
that  oppose ;  false  teeth  are  easily  lost  or  broken  and  are  not  always 
considered  an  acceptable  substitute.  Eejection  for  defective  teeth 
(9  per  cent,  in  one  lot  of  10,000  rejections)  indicates  that  we,  as  a 
nation,  have  been  most  careless  about  this  important  aid  to  proper 
digestion  of  foods. 

Defective  eyesight  caused  over  21  per  cent,  of  the  exemptions  in  a 
lot  of  10,000  soldiers  in  eight  camps  as  reported  by  Crowder.  Eye- 
sight is  more  important  than  in  any  previous  war ;  fighting  on  land 
and  sea  is  done  at  such  long  range  against  odds  before  unknown 
{e.g.,  protective  coloring,  camouflage,  heads  visible  only  behind 
trenches).  The  usual  hearing  standard  is  ability  to  distinguish 
words  spoken  in  a  low  voice  at  a  distance  of  50  feet.  Corrective 
treatment  may  be  given  for  defects  of  the  eye,  ear,  nose,  and  teeth, 
if  the  men  are  otherwise  acceptable. 


MILITARY  HYGIENE  331 

Nervous  instability  and  mental  affectionfl  have  never  been  more 
important  causes  of  rejection  than  in  this  present  war,  with  its 
multiplied  and  refined  horrors. 

Special  requirements  are  made  for  service  in  special  depart- 
ments; for  example,  aviation  demands  unusually  keen  eyesight,  a 
strong  heart,  elastic  lungs,  less  sensitive  or  less  easily  irritated 
mucous  membranes  (nose,  etc.),  and  a  positive  sense  of  balance  and 
direction. 

Entrance  Treatment  for  Communicable  Diseases. — ^Com- 
municable diseases  are  causes  for  rejection  in  time  of  peace;  now 
there  is  a  general  tendency  to  accept  men  in  curable  stages  of  cer- 
tain diseases,  placing  them  in  special  squads  during  treatnient. 
Such  treatment  is  now  accorded  meningitis  carriers  ^  and  those 
having  gonorrhoea  or  syphilis. 

Rejection  Figures. — The  exemptions  in  order  of  importance, 
as  given  by  various  military  authorities,  differ  with  the  conditions 
of  peace  or  war,  and  with  the  sanitary  progress  of  the  times,  that 
is,  our  ability  to  cure  or  cope  with  certain  diseases.  The  order  in 
importance  of  the  main  causes  for  1898,  for  example,  was  defec- 
tive development  (25  per  cent.),  defective  eyesight,  circulatory  dis- 
eases, genito-urinary  diseases,  digestive  diseases,  bad  character, 
deafness.  In  the  present  enlistment  Crowder's  report  on  eight 
camps  (10,000  rejections)  gives  the  order  as  eyes  (21  per  cent.), 
teeth  (9  per  cent.),  hernia  (7  per  cent.),  heart  disease  (6  per 
cent.),  ear  (6  per  cent.),  tuberculosis  (5  per  cent.),  defective  de- 
velopment (4  per  cent.),  venereal  disease  (4  per  cent.),^  mentally 
deficient  (4  per  cent.),  etc. 

Having  selected  soldiers  of  good  general  health  and  resistance, 
and  protected  them  against  the  diseases  common  in  military  experi- 
ence, the  next  problem  is  to  keep  them  well,  despite  the  strain  and 
dangers  of  warfare.  In  military  as  well  as  in  civil  life,  the  emphasis 
is  on  prevention  rather  than  treatment. 

^  Disinfectants  may  be  applied  directly  to  the  nasal  membranes.  Better 
results  seem  to  be  secured  by  inhaling  certain  drugs  {e.g.,  chloramin).  In 
most  carriers  the  organisms  die  off  in  about  a  month. 

^  This  does  not  include  all  the  actual  applicants.  Those  with  evident 
physical  defects  or  in  advanced  stages  of  venereal  disease  may  be  rejected 
in  the  regular  physical  examination.  Present  estimates  indicate  that  if 
preliminary  selection  had  not  been  adopted  the  rate  would  approach  30 
per  cent. 


332  HOME  AND  COMMUNITY  HYGIENE 

It  is,  of  course,  impossible  to  describe  in  one  chapter  the  sanita- 
tion details  practiced  in  the  army  and  navy.  They  deal  chiefly  with 
clothing,  bathing,  water,  food,  care  of  the  body  (including  the  feet), 
and  prevention  as  well  as  treatment  of  communicable  and  insect- 
borne  diseases  and  the  treatment  of  wounds. 

Clothing. — The  clothing  is  mainly  of  wool,*  chiefly  because  wool 
(1)  is  warmer  (numerous  air  spaces  between  the  fibers)  ;  (2)  gives 
water  up  slowly  and  is  therefore  less  likely  to  chill  the  body  as  the 
wet  clothes  dry;  and  (3)  can  be  made  waterproof  by  treatment  with 
oil  (lanolin),  thus  replacing  the  "waterproofing  of  the  original 
owner."  Underwear  is  also  preferably  of  wool,  and  three  different 
weights  are  supplied  our  men.  Abdominal  bands  of  woolen  ma- 
terial are  used  commonly  to  prevent  chilling  of  the  abdomen  and 
predisposition  to  intestinal  diseases.  Socks  of  three  different  weights 
are  usually  used,  one  being  cotton.  The  average  life  of  a  sock  is  fifty 
to  eighty  road  miles.  Some  of  the  European  armies  use  pieces  of 
cloth  or  long  strips  of  cloth  instead  of  stockings,  claiming  they  are 
less  liable  to  cause  blisters ;  some  use  a  coating  of  grease  only. )  The 
American  army  has  a  good  type  of  shoe — flat-soled,  flexible  leather, 
shaped  much  like  the  natural  shape  of  the  foot,  with  the  median  line 
running  through  the  big  toe  to  the  middle  of  the  heel.  Shoes  are 
usually  treated  with  shoemaker's  dubbing  (equal  parts  linseed  oil 
and  dissolved  rubber)  to  make  them  waterproof.  Twenty-five  per 
cent,  of  the  marching  men  suffer  with  foot  troubles  during  the  first 
ten  days.  Frequent  changes  of  socks  (as  at  midday  halts),  lessen- 
ing of  the  perspiration,^  and  decreasing  the  friction  (talcum  pow- 
der) are  all  important  aids. 

'  How  important  good  shoes  are  one  rarely  realizes,  until  one 
reads  that,  except  on  asphalt  or  other  made  roads,  large  armies 
always  march  in  dust  or  mud.  Dirt  moist  enough  not  to  fly  up  as 
dust  is  quickly  compressed  into  mud. 

*  Recently  there  has  been  great  excitement  over  shoddy  or  used-over 
wool.  A  good  part  of  all  woolen  goods  is  said  to  be  made  of  old,  used 
fibers;  the  price  would  probably  be  prohibitive,  if  such  renovated  wool  were 
not  used.  It  can,  of  course,  be  cleansed  thoroughly,  and  be  made  as  safe 
and  as  sanitary  as  fresh  fibers  can.  Merino  is  really  one-third  cotton,  but 
is  commonly  thought  of  as  woolen  goods. 

**  Feet  may  be  toughened  by  soaking  them  in  warm  solution  of  alum  or 
salt.  Perspiration  may  be  directly  affected  by  zinc  or  salicylic  acid  oint- 
ment. Sometimes  the  talcum  is  mixed  with  salicylic  acid  (talc  87  parts, 
starch  10  parts,  and  salicylic  acid  3  parts). 


MILITARY  HYGIENE  333 

Blankets  are  often  made  waterproof  by  soaking  in  linseed  oil,  or 
by  alternate,  soakings  in  aluminum  sulphate  and  soap.  Rubber  sur- 
faces are  sometimes  applied.  While  materials  so  treated  are  in- 
valuable for  occasional  use  (driving  rains),  or  for  bedding  (to  keep 
out  ground  moisture),  they  are  not  desirable  for  clothing,  as  they 
keep  in  the  heat  and  perspiration. 

Bathing. — Bathing  is  required;  the  feet  or  other  chafed  parts 
being  specially  cared  for  at  noon  halts,  etc.  At  camps  ingenious 
bathing  facilities  have  been  improvised  {e.g.,  a  barrel  with  holes) 
for  giving  a  shower  bath.  In  regions  where  water  is  scarce,  the 
bathing  water  is  sometimes  collected,  treated  with  lime  to  throw 
down  or  precipitate  the  soap  and  dirt,  passed  through  settling  tanks, 
and  treated  in  the  third  or  last  tank  with  washing  soda  to  precipi- 
tate the  lime;  oily  material  is  skimmed  off  the  surface  by  cloth 
strainers,  and  the  water  is  then  passed  through  a  charcoal  filter  and 
stored  in  a  temporary  tank  until  used.  By  this  method  it  is  possi- 
ble to  get  a  good  bathing  water,  odorless,  clean-looking,  and  capable 
of  a  good  lather.  It  is  possible  in  this  way,  with  two  thousand  to 
four  thousand  gallons  of  water,  to  afford  shower  facilities  for  two 
thousand  a  day.  The  sediment  or  sludge  is  buried,  and  the  Avater 
can  in  this  way  be  used  an  indefinite  number  of  times. 

The  socks  are  washed  daily,  when  the  feet  are  washed.  If  the 
underclothing  cannot  be  washed  daily,  it  should  be  at  least  aired  and 
dried  and  rubbed  to  remove  dust,  etc. 

Drinking  Water. — Drinking  water  is  a  great  problem,  natu- 
rally. Each  soldier  has  a  canteen,  which  is  scalded  thoroughly  when 
new  and  occasionally  thereafter.  He  is  warned  to  drink  little  while 
marching,  especially  during  the  early  part  of  the  marches,  as  that 
often  leads  to  drinking  water  from  other  and  often  unsafe  sources 
later  in  the  day.  (The  exchange  of  canteens  is,  of  course,  to  be 
discouraged.  It  would  also  be  a  help  if  the  distinction  between 
necessity-thirst  and  habit-thirst  drawn  by  Ford  could  be  made  clear. ) 

In  enemy  country  where  wells  are  often  filled  up  or  dynamited 
good  well  water  is  scarce.  In  the  recent  war  they  have  been  found 
to  be  contaminated  with  disease  organisms  or  filth,  such  as  human 
or  barnyard  wastes.  At  all  times  surface  streams  or  lakes  receive 
drainage  from  unknown  or  unprotected  regions.  The  problems  are, 
therefore  (1)  securing  enough  water,  and  (2)  insuring  its  safety. 
Even  in  hospitals  and  camps  in  our  own  country  water  has  been  a 
great  problem  in  the  recent  war. 


334  HOME  AND  COMMUNITY  HYGIENE 

On  the  march  canteens  may  occasionally  be  filled  directly  from 
the  streams,  the  animals  being  watered  below,  and  washing,  etc., 
being  done  still  further  down  stream.  Drinking  or  canteen  water 
should  be  boiled  or  chemically  treated  in  the  great  majority  of  con- 
ditions. It  may  be  boiled  in  huge  kettles  and  cooled  over  night  for 
the  next  day's  supply.    The  navy  distills  its  water  from  the  ocean. 

Chemical  Water  Treatment. — Chemical  treatment  is  the 
usual  method  in  our  own  army.  We  have  two  main  methods  which 
seem  satisfactory.  One  is  the  Darnell  filter  method — a  combination 
of  chemical  precipitation  and  filtration.  Alum  and  sodium  car- 
bonate are  used  as  precipitating  agents,  in  proportions  of  about  one 
pound  to  five  hundred  gallons  of  water.  This  apparatus  has  for 
bacterial  removal  an  efficiency  of  about  90  to  95  per  cent.  As  shown 
by  the  description  accompanying  the  diagram  (Fig.  99),  it  is  easy 
to  operate,  and  is  easily  transported,  put  up,  etc. 

The  second  method  is  primarily  chemical,  though  in  the  case  of 
a  very  muddy  water  it  may  be  first  filtered.  Our  army  uses  for 
this  purpose  the  Lyster  bag,  a  waterproof  canvas  bag  with  several 
faucets  at  the  bottom.  To  this  bag  containing  forty  gallons  of 
water  is  added  one  gram  of  chlorinated  lime  (see  Appendix), 
which  is  kept  in  one-gram  capsules  ready  for  this  use.  This  is 
a  rather  stronger  solution  than  is  used  in  city  water  sup- 
plies, being  somewhat  over  three  parts  to  a  million  parts  of  water. 
In  half  an  hour  the  water  may  be  used  for  drinking  purposes. 
Water  wagons  are  also  used;  they  are  essentially  tanks  to  which 
chlorinated  lime  can  be  added,  and  have  the  added  advantage  of 
locomotion.     One  water  wagon  holds  125  gallons. 

Disposal  of  Waste. — The  disposal  of  human  excreta  is  a  big 
problem,  especially  in  trench  life.*    There,  special  boxes  with  metal 

°  The  hardships  of  life  in  the  trenches  are  real  to  most  of  us,  but  we 
fail,  usually,  to  appreciate  fully  the  hygienic  problems.  In  the  covered 
trenches,  men  are  sometimes  30  to  40  feet  underground  without  sunlight, 
and  with  barely  room  to  stand  erect.  But  even  the  open  ones  have  serious 
problems;  standing  water,  mud,  the  problems  of  excreta  disposal,  and  such 
pests  as  rats  and  insects  ( flies  from  No  Man's  Land,  lice,  etc. ) .  Men  are 
crowded  in  very  small  quarters,  often  one  man  to  a  square  yard,  which  must 
accommodate  four  or  more  in  time  of  actual  combat.  The  periods  in  the 
trenches  are  as  short  as  the  circumstaaices  permit — usually  about  a  week, 
however.  With  all  these  handicaps,  there  has  been  surprisingly  little 
sickness,  due  primarily  to  the  practical  elimination  of  intestinal  disorders 
by  vaccines. 


MILITARY  HYGIENE 


335 


receptacles  are  used  as  latrines  (G) ;  these  cans  are  emptied  at  least 
daily,  the  contents  being  taken  back  of  the  trench  lines,  often  sev- 
eral miles.  Separate  cans  are  often  provided  as  urinals,  to  simplify 
the  process  of  burial,  disinfection,  etc.  On  the  march  or  in  tem- 
porary camps  pits  or  trenches  are  used  where  the  conditions  permit 
{e.g. J  where  the  soil  is  not  too  rocky).    These  are  as  far  from  the 


G 


» 


Fig.  99. — Water  filter  in  use  in  the  United  States  Army.     In  use,  a  canton  flannel  cover  is 
placed  over  the  frame  shown  on  the  right. 

kitchens  as  possible,  to  eliminate  fly  transfer  of  typhoid,  dysentery, 
etc.  These  pits  or  trenches  vary  greatly  with  the  permanence  of  the 
camp.  They  may  be  simply  soft  dirt  trenches,  they  may  have  a 
loose  wall  or  drainage  base,  or  they  may  even  have  wooden  or 
screened  tops,  with  covers  so  adjusted  that  they  fall  shut  when  not 
held  open  (Fig.  100).  Garbage  is  similarly  disposed  of,  usually. 
Garbage  and  latrine  pits  may  be  simply  filled  with  dirt,  taking 
care  that  the  edges  are  free  from  objectionable  material.  These 
edges  and  the  pits  themselves  are  sometimes  treated  with  chemical 


336 


HOME  AND  COMMUNITY  HYGIENE 


disinfectants,  such  as  lime.  More  often  the  pits  are  burned  out  in- 
stead, first  flooding  them  with  crude  oil.  Sometimes  these  pits,  espe- 
cially the  garbage  pits  when  designed  for  long  periods  of  use,  are 
specially  constructed  to  facilitate  the  burning  process  {e.g.,  loose 
rock  piles  which  allow  the  liquids  to  drain  into  the  ground,  and 
provide  better  aeration  for  the  burning  of  solids;  see  pages  167 
and  397). 

Food. — The  bacterial  phases  of  the  food  problem  {e.g.,  when 
prepared  by  cooks  infected  with  dysentery)  are  discussed  separately 
under  transfer  of  disease  (Chapter  IX). 

The  mechanical  phases  of  food  preparation  are  those  of  the  ordi- 


Fig.   100. — Pit  or  latrine  cover;  the  central  block  prevents  the  lida  from  etaying  open. 

nary  home  or  hotel.  Dishes  should  be  washed  thoroughly  by  a 
special  detail  and  rinsed  in  boiling  water;  uncooked  foods  should 
be  washed  or  served  from  original  wrappings  or  packages. 

Food  should  meet  the  requirements  already  discussed  in  Chapter 
III,  on  Food.  The  effect  of  appearance  and  flavor  on  digestion, 
the  necessity  for  enough  food,  and  the  right  kinds  of  foods,  need 
not  be  repeated  here.  We  find  the  training  camps  substituting 
vegetables  for  other  foods  whenever  possible.  But  vegetables  and 
milk  probably  do  not  figure  so  largely  in  the  dietaries  as  might  be 
possible.  Since  the  aim  of  the  government  is  efficient  fighting  men, 
and  it  has  long  been  recognized  that  "  an  army  travels  on  its  stomach 
as  well  as  its  feet,"  every  effort  is  made  to  provide  an  adequate  diet. 

Army  Rations. — Very  contradictory  statements  are  made  by 
soldiers  and  even  by  texts  concerning  military  rations.'^    The  army 

'  A  ration  is  the  food  allowance  for  one  day. 


MILITARY  HYGIENE 


337 


and  navy  rations  differ ;  another  reason  is  that  we  have  all  possible 
camp  modifications  of  the  standard  diet,  which  is  roughly  11  per 
cent,  protein,  10  per  cent,  fat,  46  per  cent,  sugars  and  starches,  and 
the  balance  water,  minerals,  and  indigestible  material.  Another 
reason  for  the  different  reports  is  that  the  army,  for  example,  has 
five  rations:  a  garrison  ration,  a  travel  ration,  a  reserve  ration,  a 
field  ration,  and  an  emergency  ration.  The  field  supply  trains  each 
carry  at  least  two  field  rations  for  each  man.  Each  man  carries  in 
his  kit  two  reserve  rations ;  these  are  not  to  be  used  except  when  so 
directed  by  the  commanding  officer  (see  following  table). 
American  Army  Rations 


Garrison  ration 


Article 


Beef. 


.20 


Flour  or  bread .  18 

Baking  powder      .08 

Beans 2.4 

Potatoes 20 

Prunes 1.28 

Coflfee 1.12 

Sugar 3.2 

Milk  (evap.)..  .  0.5 

Vinegar 16  gill 

Salt 64 

Pepper,  black.  .     .04 

Cinnamon 014 

Lard 64 

Butter 5 

Syrup 32  gill 

Lemon  extract.     .014 


Approximate 
net  total .  . 


.69 


Field  ration 


Article  oz. 

Beef 14 

Bacon.  .  .  3.6 
Bread ...  16 


Beans.  . .   4 
Potatoes  14 
Tomatoes  5 
Prunes.  .    1.28 
Coffee..  .   1.12 
Sugar.  .  .    2.4 


Salt 16 

Pepper.  .     .02 


62  oz. 


Reserve  ration 


Article  oz. 

Bacon. . .12 
Hard 
bread. .16 


Coffee... 
Sugar.  .  . 

Salt 


1.12 
2.4 


.16 


32  oz. 


Travel  ration 


Article  oz. 

Beef,  corned.  12 
Bread 18 


Beans,  baked .  4 


Tomatoes.  . 

Jam 

Coffee 

Sugar 

Milk  (evap. 


1.4 

1.12 

2.4 

.5 


47  oz. 


8  oz. — divided  into  3  cakes,  sealed  tin  can 


Emergency  ration 

45  per  cent,  chocolate  liquor 
7  per  cent,  nucleocasein 
7  per  cent,  malted  milk 
15  per  cent,  egg  albumin 
22  per  cent,  powdered  cane  sugar 
4  per  cent,  cocoa  butter 
balance  water 

Another  concentrated  food  of  high  value  is  pemmican:   dried  lean  beef 
tallow,  currants,  sugar,  pressed  into  cakes  supplemented  by  chocolate. 


338  HOME  AND  COMMUNITY  HYGIENE 

While  travelling  these  diets  may  be  left  partly  to  the  soldier; 
he  has,  for  example,  a  cash  allowance  as  "  hot-coffee  money." 

The  standard  ration  is  about  5000  calories  a  day.  This  is  fixed 
by  Congress,  but  the  ration  is  flexible  as  to  the  items  composing 
the  diet.  For  example,  in  the  garrison  ration  beans  may  be  replaced 
by  rice  or  hominy;  prunes  by  peaches,  apples,  or  jam;  vinegar  by 
pickles;  or  beef  by  mutton  (30  ounces),  bacon  (12  ounces),  dried 
fish  (14  ounces),  chicken  (16  ounces),  etc. 

Prevention  of  Disease. — The  regulations  already  discussed 
show  that  in  military  as  well  as  civil  life  the  "  ounce  of  prevention 
is  worth  a  pound  of  cure."  The  men  selected  must  be  well  and 
hardy.  Food,  clothing,  exercise,  and  body  care  must  help  keep  them 
fit.  Garbage  and  other  wastes  must  be  disposed  of  in  such  ways 
that  they  are  not  a  menace  to  health. 

The  regulations  also  forbid  drinking  water  from  unauthorized 
sources,  and  buying  food  (unless  in  original  packages)  from  un- 
licensed venders,  since  the  danger  from  such  diseases  as  typhoid, 
dysentery,  and  tuberculosis  is  so  great. 

Disease  is  also  guarded  against  in  more  definite  ways.  Men 
infected  with  communicable  diseases  are  either  rejected  or  segre- 
gated during  curative  treatment  (see  p.  331). 

Typhoid  and  dysentery  carriers  are  not  allowed  to  prepare  food. 
All  men  are  vaccinated  against  smallpox,  even  if  they  have  been 
previously  vaccinated.  Every  man  is  also  vaccinated  against 
typhoid.  This  vaccine,  contrary  to  the  navy  practice,  was  given 
in  the  army  in  one  dose;  this  is  a  special  glycerin  combination 
found  to  be  as  successful  as  the  several  injections  formerly  used. 
Mixed  with  it  we  give  killed  paratyphoid  (G)  organisms  and  killed 
dysentery  organisms.  It  is,  however,  commonly  spoken  of  by  the 
men  as  typhoid  vaccine,  for  many  of  them  do  not  realize  that  it  is  a 
triple  vaccine  (see  p.  203). 

Some  responsibility  is  put  upon  the  men  for  keeping  well. 
There  are  bi-monthly  physical  examinations  and  those  suffering  from 
venereal  disease  must  report  for  treatment ;  failure  so  to  report  is  a 
court-martial  offence;  men  not  on  duty  (or  on  sick  leave)  receive 
no  pay  when  alcohol  or  venereal  diseases  are  the  causes. 

Losses  from  Disease. — It  is  generally  known  that  formerly  dis- 
eases, such  as  typhoid,  caused  more  of  the  war  losses  than  the  acci- 
dents of  battle  (including  the  killed  and  mortally  wounded).     In 


MILITARY  HYGIENE 


339 


our  own  Civil  War  the  deaths  from  disease  among  the  white  soldiers 
were  nearly  twice  the  other  deaths ;  among  the  negro  soldiers  they 
were  nearly  nine  times  as  many.  The  Spanish-American  War  was 
relatively  short,  and  physical  exhaustion  must  have  played  a  minor 
part  as  a  predisposing  factor,  yet  the  ratio  there  was  almost  six 
to  one. 

In  each  of  several  of  the  recent  wars,  however,  the  Franco- 
Prussian,  the  Eusso-Japanese,  and  the  Boer  War,  one  or  more  of 
the  participating  countries  demonstrated  that  it  was  possible  to 


Fig.   101. — Typhoid  is  now  relatively  unimportant  as  an  army  disease.     Why? 


reduce  markedly  the  deaths  from  disease.  In  our  recent  Mexican 
difficulties  the  typhoid  figures — ^but  one  case  (or  two?)  among  over 
12,000  soldiers — showed  that  control  was  possible  even  under  such 
unusual  difficulties  as  limited  water  supply,  difficult  climatic  con- 
ditions, and  all  the  problems  of  long-distance  transportation  (see 
also  Fig.  101). 

Typhus  Fever. — Having  established  the  value  of  sanitary  con- 
trol of  food,  water,  human  wastes,  etc.,  and  of  such  immunizing 
methods  as  vaccination  against  dysentery,  typhoid,  smallpox, 
cholera,  and  even  plague,  we  were  hardly  prepared  for  the  death  rates 
from  typhus  fever  in  the  early  part  of  the  recent  war.  The  knowledge 
that  the  disease  is  spread  bythebody  louse  (and  also  by  the  head  louse) 
has  made  possible  the  control  of  that  disease.     The  head  is  shaven 


340  HOME  AND  COMMUNITY  HYGIENE 

— at  least  the  part  near  the  neck;  nurses  and  doctors  wear  clothes 
fastened  tightly  at  the  ankle  and  wrist,  to  prevent  lice  from  reach- 
ing the  body;  bathing  is  enforced;  in  many  parts  of  battle  lines 
during  war  time  delousing  stations  were  established  at  distances 
,making  it  possible  to  treat  each  individual  at  short  intervals — every 
ten  days,  at  least.  These  delousing  houses  are  little  shacks  supplied 
with  hot  water  and  steam,  and  usually  consist  of  four  rooms  or  com- 
partments. The  man  enters  by  one,  hands  his  clothes  in  to  a  second 
to  be  sterilized  while  he  himself  passes  to  a  third  for  a  complete  bath, 
including  the  head.  As  he  passes  on  to  the  fourth  room,  his  steam- 
sterilized  clothes  are  handed  to  him,  and  he  leaves  the  station 
from  that  fourth  safe  room.  Several  thousand  can  be  treated  each 
day  in  one  of  these  small  stations.  Similar  delousing  stations  were, 
during  the  later  .years  of  the  war,  in  use  on  the  western  front  for  pre- 
vention of  trench  fever  (see  p.  341). 

The  typhus  rates  during  the  first  two  years  of  the  war  were  not 
so  much  a  reflection  upon  military  sanitation  as  upon  the  peoples 
of  central  Europe.  In  many  of  them  typhus  fever  is  endemic; 
louse-infested  people  and  others  sick  with  typhus  formed  part  of  the 
fleeing  thousands  of  civilians  who  had  to  be  cared  for  in  the  crudest 
of  shelters,  particularly  along  the  southern  front.  The  ill,  the 
wounded,  and  prisoners,  too,  were  housed  in  the  same  kind  of 
sheds,  often  without  any  water  supply  at  all,  sleeping  on  straw  or 
the  floor  itself,  often  so  close  together  that  their  bodies  actually 
touched.  Such  dark,  often  entirely  windowless,  shacks,  without 
water  and  without  privies,  filled  with  people  possessing  no  changes 
of  clothing,  were  pest  houses  we  cannot  picture.  Without  drugs  or 
medicines,  the  few  overworked  doctors  and  nurses  in  such  regions 
struggled  bravely.  They,  themselves,  died  off  at  a  fearful  raie,  over 
60  per  cent,  in  some  localities  on  the  southern  front.  The  greater 
stability  of  the  battle  lines  has  lessened  the  migration  of  infected 
peoples  and  enabled  military  authorities  to  care  properly  for  their 
own  soldiers  as  well  as  infected  prisoners,  and  typhus  fever  may  now 
be  classed  with  the  controlled  diseases. 

Tuberculosis. — Tuberculosis  assumed  alarming  proportions, 
especially  among  the  French.  It  was  low  among  the  English, 
because  England  had  met  the  tuberculosis  problem  before  the  war 
began,  while  in  France  practically  nothing  had  been  done  (see 
p.  302).    The  tuberculosis  rates  in  the  French  army  were  formerly 


MILITARY  HYGIENE  341 

next  to  typhoid.  The  French  army,  which  was  mobilized  in  such 
haste  and  with  regard  to  numbers  only  was  thought  to  contain  over 
a  half  million  tubercular  cases;  while  the  English  army  of  over 
5,000,000  men,  mobilized  more  deliberately  with  physical  examina- 
tions, had  no  real  tubercular  problem  at  all.  The  relative  freedom 
of  the  English  is  attributed  partly  to  their  attitude  toward  fresh  air 
and  outdoor  exercises. 

Other  War  Conditions. — There  were  in  the  late  war  other 
diseases  relatively  new — at  least  in  the  proportions  in  which  they 
existed — incident  to  the  changed  methods  of  warfare.  "  Trench 
fever,"  though  rarely  fatal,  is  serious  in  the  total  illness  rates,  espe- 
cially as  one  attack  does  not  protect  against  a  second.  Recent  in- 
vestigation indicates  that  this,  like  typhus  fever,  is  a  louse-borne 
disease.  It  may  be  a  "  short  fever  of  about  a  week's  duration," 
often  followed  by  a  short,  single  relapse;  or  it  may  be  a  longer 
illness  with  a  number  of  sharp,  periodic  relapses.  It  is  not  re- 
lapsing fever,  with  which  it  has  been  confused. 

"  Trench  foot "  is  another  new  disease,  traceable  probably  to  ex- 
posure (cold,  mud,  slush),  but  mainly  to  muscular  inactivity,  due 
to  the  confined  trench  quarters,  especially  in  the  long-sustained  sit- 
ting positions  where  the  pressure  of  the  seat  under  the  knees  slows 
the  circulation.  The  shrinkage  of  the  woolen  puttees  worn  by  the 
English  also  restricts  the  circulation,  predisposing  to  this  disease. 

Other  war  diseases  are  infectious  jaundice  (Weil's  disease),  caus- 
ing but  a  low  mortality  (2  to  3  per  cent,  of  those  infected),  and 
war  or  trench  nephritis  (G)  ;  the  latter,  while  not  often  fatal,  is 
important  as  an  epidemic  disease,  and  because  it  tends  to  show  up 
later  in  kidney  disturbances.  Kidney  diseases  are  so  important  in 
adult  life  that  such  predisposing  factors  must  be  looked  upon  as 
dangerous.  It  is  thought  that  infectious  jaundice  is  a  disease  trans- 
ferred through  the  rat ;  the  cause  of  war  nephritis  is  as  yet  wholly 
unknown. 

Nervous  Disorders. — Functional  nervous  disturbance,  such  as 
blindness,  deafness,  insanity,  and  paralysis  due  mainly,  if  not  en- 
tirely, to  shell  shock,  and  nervous  exhaustion  due  to  extreme  or 
continued  strain,  have  been  more  prominent  in  the  late  war,  with 
its  new  and  terrible  methods  of  warfare,  than  in  any  earlier  war. 

Gas  Poisons. — Gas  poisons,  such  as  chlorine,  are  mainly  in- 


342  HOME  AND  COMMUNITY  HYGIENE 

jurious  because  of  their  effect  iipon  the  delicate  membranes,  eyes, 
nasal  passages,  lungs.  They  cause  pain  {e.g.,  smarting  of  the  eyes), 
or  such  a  copious  flow  of  secretions  to  remove  the  exciting  substances 
that  these  secretions  interfere  with  sight,  or  clog  the  lung  mem- 
branes, thus  interfering  with  breathing,  and  often  causing  suffoca- 
tion for  lack  of  oxygen.  Carbon  monoxide  used  in  explosives  may 
be  responsible  for  many  cases  of  gas  poisoning  (see  CO,  p.  132). 

Occasionally  milder  nauseating  gases  are  used.  These  are  im- 
portant only  because  they  cause  the  removal  of  the  protective 
masks,  leaving  the  men  unprotected  for  the  subsequent  attack  of 
more  irritating  gases. 

The  meeting  of  the  gas  problem  was  one  of  the  thrilling  episodes 
of  the  war.  When  first  used  in  1915,  the  Allies  were  wholly  unpre- 
pared and  a  hasty  conference  was  called  in  England.  Procedures 
were  agreed  upon,  factories  commandeered,  and  thousands  of  masks 
were  conveyed  across  the  Channel  and  in  use  in  France  in  less  than 
seventy-two  hours  after  the  conference  met. 

Wound  Treatment. — The  treatment  of  wounds  deserves  a 
chapter  by  itself,  for  they  have  always  been  a  big  item  in  the  losses 
due  to  war.  Before  Lister's  work  just  after  our  Civil  War,  surgery 
was  in  the  same  deplorable  state  it  had  always  been:  over  99  per 
cent,  of  all  abdominal  operations  were  fatal;  so  were  over  60  per 
cent,  of  all  other  major  operations,  such  as  the  removal  of  a  leg 
or  an  arm.  One  surgeon  in  the  Civil  War  was  seen  to  clean  his 
knife  on  his  boot  before  using  it  to  cut  off  the  leg  of  a  wounded 
soldier. 

That  bacteria  were  present  in  wound  infections  was  not  posi- 
tively shown  until  1866  to  1877,  though  such  theories  were  ad- 
vanced earlier  than  that,  and  supporting  evidence  was  given  by 
Oliver  Wendell  Holmes  in  1843.  Bacteria  were  not  seen  in  animal 
tissues  until  1849,  and  not  in  human  blood  or  (human)  tissues  until 
1866.  It  was  commonly  thought  that  suppuration  was  an  early 
and  even  necessary  stage  in  healing ;  and  occasionally  one  still  hears 
it  said  of  a  wound  that  "it  must  grow  worse  before  it  can  grow 
better." 

Since  Lister's  work  with  disinfectants  and  antiseptics,  wounds 
have  been  treated  very  differently.  His  work  has  made  possible  all 
the  marvels  of  modem  surgery.  Every  effort  is  made  to  keep  the 
wounds  free  from  bacteria. 


MILITARY  HYGIENE  343 

Our  soldiers  are  supplied  with  first-aid  packets,  containing  usu- 
ally two  bandages  and  two  compresses  made  of  dry  gauze  soaked  in 
corrosive  sublimate,  and  two  safety  pins,  (These  are  wrapped  in 
waxed  paper  to  keep  them  sterile.) 

In  the  European  war,  wound  infections  were  an  unexpectedly 
serious  problem,  because  of  two  things — the  type  of  wounds  com- 
monly found  and  the  kinds  of  organisms  often  present.  Liquid 
fire  often  causes  very  large  burned  areas  on  the  body;  the  explo- 
sives of  to-day  make  wounds  which  are  not  only  much  larger  and 
more  numerous,  but  contain  irregular  deep  pockets  which  are  most 
difficult  to  reach.  In  many  cases  in  this  war  it  has  been  impossible 
to  rescue  the  wounded  promptly,  and  in  many  cases  wounds  have 
therefore  been  in  a  very  bad  condition  before  the  patient  could 
be  eared  for. 

There  are  two  main  methods  of  treating  such  wounds :  (1)  The 
wounds  may  be  thoroughly  cleansed  surgically  and  sewed  up  at  once. 
Clean  wounds  usually  heal  promptly,  (2)  The  second  method, 
which  has  been  given  much,  prominence  in  the  late  war,  is  com- 
monly known  as  the  Carrel-Dakin  method.  Even  wounds  already 
green  with  pus  or  ridged  with  proud  flesh  have  been  healed  in  a  re- 
markably short  time  by  this  method.  The  wound  is  cleansed  surgi- 
cally as  far  as  the  conditions  will  allow.  It  is  then  irrigated  by  a 
weak  hypochlorite  solution,  specially  prepared  to  avoid  undue  irrita- 
tion of  the  tissues  and  to  insure  a  known  strength.  This  ma- 
terial is  kept  in  a  flask  at  the  head  of  the  bed.  From  this  flask 
runs  a  rubber  tube  one-quarter  to  one-half  inch  in  diameter  with 
several  branches  and  sub-branches,  often  as  many  as  twelve  or 
sixteen.  An  end  runs  into  each  little  recess  or  pocket  of  the  wound, 
and  a  small  amount  slowly  washes  the  tissues.  At  intervals — every 
two  hours,  commonly — ^the  pinch-cock  or  regulator  is  opened  and  a 
generous  amount  of  liquid  runs  out  of  each  tip  into  the  wound, 
flushing  it.  With  this  treatment  the  bacteria  are  lessened  rapidly ; 
how  rapidly  is  shown  by  a  little  material  from  the  wound  which  is 
put  upon  a  slide,  stained  for  bacteria,  and  examined  with  a  micro- 
scope. When  the  bacteria  on  the  slide  average  but  one  to  five  in 
each  view  through  the  microscope,  it  has  been  found  safe  to  sew  up 
the  wound.  Wonderful  results  have  been  secured  by  this  method; 
indescribably  infected  wounds  have  been  cleansed  and  made  ready 
to  sew  up  in  four  to  nine  days.     In  ordinary  wounds  the  Carrel- 


344 


HOME  AND  COMMUNITY  HYGIENE 


Dakin  treatment  is  not  "usually  necessary  for  more  than  two  to  five 
days.  Some  months  ago  Doctor  Carrel  reported  that  but  one  wound 
so  treated  and  examined  had  failed  to  heal  properly. 

The  organisms  which  have  caused  most  of  the  wound  difficulties 
in  the  Euroj)ean  war  are  the  tetanus  bacillus  and  the  gas  bacillus 


*  J*  •  •  / 


■^.%'- 


■i'K% 


•»• 


1  • 


»    ■» 


Fig.   102. — Gas  bacillus;  spores  on  the  right. 

(Fig.  102).  They  are  both  found  in  the  intestines  of  man,  cow, 
horse,  etc.,  and  may  form  spores,  living  a  long  time  in  manure- 
polluted  soils.  The  highly  cultivated  soil  of  central  Europe  con- 
tains many  of  these  organisms ;  wounds  are  easily  infected  with  soil, 
especially  in  the  present  methods  of  warfare  (explosive  shells  which 
break  in  or  near  the  ground,  etc.). 

Tetanus  or  lockjaw  is  prevented  from  developing  in  such  wounds 
by  injecting  all  probably  infected  wounds  with  tetanus  antitoxin 
(see  p.  207).  Lockjaw  was  soon  under  control,  due  in  great  part  to 
the  large  amount  of  high-grade  tetanus  antitoxin  supplied  by  the 
United  States. 


MILITARY  HYGIENE  345 

The  gas  bacillus  ^  is  harder  to  deal  with,  but  recently  Bull  has 
developed  an  antitoxin  for  this  gas  bacillus ;  it  was  tried  out  on  the 
western  front,  and  when  the  armistice  came  was  giving  most 
encouraging  results  in  uncomplicated  cases.  The  gangrenous  con- 
dition which  often  develops  has  led  to  the  name  "gas-gangrene 
bacillus/^  Work  on  the  western  front  indicates  that  the  horses 
which  are  already  producing  tetanus  antitoxin  produce  a  stronger 
gas  bacillus  antitoxin  than  other  horses  (see  table,  p.  211). 

Navy  Conditions. — In  the  navy  the  conditions  are  very  differ- 
ent. The  air  space  accorded  is  considerably  less  than  the  minimum 
requirement  (see  p.  Hi).  It  is  often  as  low  as  seventy-two  cubic  feet 
with  twelve  square  feet  of  floor  space !  The  excess  of  moisture — 
due  to  the  frequent  washing  of  decks  and  floors,  the  "  bilge  "  water 
often  leaking  in  through  seams,  and  the  large  amount  of  perspira- 
tion of  the  sailors  crowded  in  such  close  quarters  tend  to  make  the 
air  very  oppressive.  Ventilating  systems  designed  to  overcome  this 
consist  of  huge  pipe  systems  with  fans,  exhausts,  etc.,  which  draw 
or  force  air  through  the  pipe  systems.  Sometimes  these  pipes  pro- 
trude above  the  deck  and  face  in  such  a  way  that  the  wind  or  the 
movement  of  the  vessel  helps  force  air  down  into  the  lower  levels ; 
often  the  iron  masts  are  used  as  ventilating  flues.  Portholes  help 
somewhat  on  the  upper  levels,  but  only  in  clear  weather,  of  course. 
With  such  rapidly  replaced  air  the  drafts  may  be  disagreeable,  and 
too  often  the  ventilators  are  closed.  Tuberculosis  and  other  respira- 
tory diseases  are  higher  among  sailors  than  in  the  army.  The  con- 
fined sleeping  quarters  may  be  responsible.  The  short  sleep  periods 
— broken  by  watches — may  be  a  real  benefit,  especially  now  with 
the  close  quarters  common  in  hot  steel  ships.  In  the  modem  battle- 
ships relatively  few  sailors  sleep  down  in  the  hull.  The  sleeping 
quarters  are  often  imperfectly  enclosed  {e.g.,  gun  decks)  and  must 
be  both  cold  and  drafty  in  severe  weather. 

The  bedding  is  aired  when  weather  permits,  but  this  is,  of 
course,  an  inadequate  compensation  for  the  other  conditions;  for 
example,  on  rising,  the  men  roll  blankets  and  hammocks  into  a  tight 
roll,    and    store  them    in   shelf-like   recesses   until    bedtime.    The 

®  The  gas  bacillus  causes  a  rapid  and  progressive  infection  of  tRe 
tissues ;  the  accumulation  of  gas  gives  the  flesh  a  papery  or  even  crackly 
feeling  under  pressure,  hence  its  name.  It  has,  of  course,  nothing  to  do 
with  the  poisonous  gas  (gas  clouds,  gas  shells)   used  recently  in  warfare. 


346  HOME  AND  COMMUNITY  HYGIENE 

beds  (bunks,  or  hammocks)  are  usually  too  close  together.  The 
hammocks  are  less  easily  cared  for  and  less  comfortable,  the  body 
being  always  bent  in  a  curve. 

The  navy  ration  is  lower  than  the  army  ration,  owing  to  the 
lees  heavy  exercise  (when  compared  with  the  soldier's  marching 
with  a  fifty-five-pound  equipment).  It  is,  like  our  army  ration, 
more  generous  than  that  of  the  other  nations.  The  ration  is  very 
elastic,  but  is  perforce  limited  in  range,  e.g.,  canned  rather  than 
fresh  vegetables.  Circumstances  affect  the  food  ( e.g.,  amount,  meal 
hours)  of  sailors  less  than  soldiers,  as  their  food  is  always  in  the 
same  boat ;  and  cooking  arrangements  are  more  stable  and  constant. 
Water  is  always  available  for  distilling;  and  the  disposal  of  gar- 
bage and  human  waste  is  no  problem  at  all,  with  the  whole  ocean 
as  a  sewer. 

PROBLEMS 

1.  What  procedures  in  military  hygiene  might  well  be  carried  over  into 
civil  society? 

2.  In  what  health  policies  or  sanitation  measures  should  cities  co- 
operate with  nearby  military  camps  ? 

3.  Allowing  for  the  "personal  equation"  what  reports  of  returned 
sailors  and  soldiers  indicate  lack  of  proper  control  of  hygienic  conditions? 

4.  List  the  helpful  or  important  facts  or  principles  of  hygiene  that 
soldiers  or  sailors  are  bringing  back  to  civil  life. 

See  Reference  List  at  end  of  Appendix. 


CHAPTER  XXIII 
RURAL  AND  URBAN  CONDITIONS 

Formerly  all  comparisons  of  city  and  rural  conditions  were 
strongly  in  favor  of  the  country.  In  Ogden's  "  Rural  Hygiene," 
he  says: 

It  is  commonly  supposed  that  good  health,  is  the  invariable  accom- 
paniment of  country  life;  that  children  who  are  brought  up  in  the  country 
are  always  rosy-cheeked,  chubby,  and,  except  for  occasional  colds,  free  from 
disease;  that  adults,  both  men  and  women,  are  strong  to  labor,  like  the 
oxen  of  the  Psalmist,  and  that  grandfathers  and  grandmothers  are  so  com- 
mon and  so  able-bodied  that  in  practically  every  farmhouse  the  daily  chores 
are  assigned  to  these  aged  exponents  of  strong  constitutions  and  healthy 
lives.  If,  however,  we  are  honest  in  our  observations,  or  have  lived  on  a 
farm  in  our  younger  days,  or  have  kept  our  eyes  open  when  visiting  in  the 
country,  we  will  remember,  one  by  one,  certain  facts  which  will  persist- 
ently suggest  that,  after  all,  life  on  the  farm  may  not  be  such  a  spring  of 
health  as  we  have  been  led  to  believe.  We  will  remember  the  frequency  of 
funerals,  especially  in  the  winter,  and  the  few  families  in  which  all  the 
children  have  reached  maturity.  We  will  remember  the  worn-out  bodies 
of  men  and  women,  bent  and  aged  while  yet  in  middle  life. 

We  have  most  of  us  heard  disquieting  rumors  regarding  the 
higher  death  rates  of  country  babies  as  well  as  adults ;  the  prevent- 
able defects  are  greater  among  country  than  among  city  children; 
and  one  almost  hesitates  to  visit  the  country,  so  widely  have  "  vaca- 
tion typhoid  "  and  similar  dangers  been  denounced. 

What  is  the  real  situation?  First  of  all  we  must  admit  that 
the  usual  idea  of  country  conditions  is  based  more  upon  general 
impression  than  upon  actual  figures.  The  registration  of  deaths 
and  undertakers'  permits  are  more  incomplete  there  than  in  the 
city;  often  there  are  no  records  at  all  of  illnesses,  even  commu- 
nicable ones. 

Mortality  Figures  Compared. — What  figures  we  have  indicate 
that  there  has  been  a  change  in  the  health  conditions.  IJp  to  1900 
(F;g.  103)  the  death  rate  in  rural  'New  York  was  less  than  in  New 
York  City,  but  now  it  is  safer  to  live  in  the  largest  city  in  the 
United  States  than  in  the  country  surrounding  it.  Biggs,  Health 
Commissioner  of  New  York  State,  says  for  that  State  that  "the 

347 


348 


HOME  AND  COMMUNITY  HYGIENE 


Death  Rate  in  New  York  City 

'Compared  with  Death  Rate 

in  Rural  New  York 


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Rural  New  York  is  entitled  to  as  good 

health  protection  as 

the  cities 


Report  of  New  York  Sate 
Department  of  Health 


Committee  on  Health  Problems  ofNatioiud  Council  of Edi 
and  American  Medical  Association 
Prepartd  by  Dr.  Thomai  D.  Wood,  515  West  laoth  Street 
New  York  City.      1918 


Fig.    103.  —What  the  city  has  done  the  country  should  do. 


RURAL  AND  URBAN  CONDITIONS 


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350  HOME  AND  COMMUNITY  HYGIENE 

rural  death  rate  from  general  diseases,  typhoid  fever,  malaria,  diar- 
rhoea, and  enteritis,  is  greatly  in  excess  of  that  in  urban  districts." 
See  also  Fig.  104  for  preventable  disease  conditions.  In  the  "  reg- 
istration area  "  ^  of  the  United  States,  however,  the  death  rate  for 
1912  is  about  the  same  for  city  and  country — 14  per  1000  in  the 
cities,  and  13  per  1000  in  the  rural  regions  of  the  States.  If  the 
areas  not  in  this  census  were  included,  the  balance  would  probably 
be  as  in  Xew  York  State,  for  regions  so  lax  as  not  to  be  represented 
in  the  registration  area  have  probably  very  low  standards  of  health 
and  sanitation. 

The  death  rate  for  children  under  one  month  is  higher  in  the 
country;  after  that  it  is  higher  for  city  children.  But  the  consid- 
eration of  real  importance  is  health,  not  deaths,  of  course,  and  the 
health  defects  and  diseases  are  much  greater  among  country  chil- 
dren than  among  city  children  (Fig.  105). 

Physical  Defects. — The  newspapers  during  the  examination 
of  drafted  men  for  our  army  have  given  alarming  figures  concern- 
ing the  relative  fitness  of  rural  and  urban  men.  A  more  recent  com- 
parison by  Provost  Marshal  General  Crowder  based  on  about  80,000 
men  examined  from  city  and  rural  localities  having  no  large  immi- 
grant element  in  ten  widely  separated  States  {e.g.,  Alabama,  Cali- 
fornia, Kansas,  New  York)  shows  that  the  conditions  in  men  of 
draft  age  are  really  much  the  same.  The  urban  areas  rejected  for 
physical  reasons  28.47  per  cent,  of  the  35,000  men  examined;  the 
rural  areas,  27.96  per  cent,  of  the  44,000  men  examined. 

The  figures  indicate  rather  that  both  rural  and  urban  condi- 
tions need  our  serious  attention,  if  nearly  three  out  of  ten  men  in 
the  prime  of  life  are  exempted  because  of  physical  disability.  Of 
these  defects  many  are  preventable :  21  per  cent,  of  the  rejections 
were  due  to  defective  eyesight,  and  over  8  per  cent,  to  defective 
teeth. 

Predisposing  Factors. — What  is  there  that  can  account  for 
the  shifting  balance  in  favor  of  city  life? 

Homes. — First,  there  are  in  the  country  many  predisposing 
factors  toward  disease,  all  of  which  are  mentioned  under  other  head- 
ings in  this  book.     They  include  poorly  protected  wells  and  springs 

*The  registration  area  included  here  represented  but  twenty-three 
other  States.  It  now  includes  twenty-six  States  and  parts  of  thirteen  other 
States   (see  Glossary,  also). 


RURAL  AND  URBAN  CONDITIONS  351 

{e.g.,  with  uncovered  or  with  leaky  covers,  receiving  surface  drain- 
age) ;  unsanitary  privies  {e.g.,  unscreened,  opening  into  brooks, 
etc. ) ;  poorly-lighted  and  poorly  ventilated  houses  and  cellars ;  too 
meagre  a  supply  of  water;  lack  of  facilities  for  washing  of  hands 
and  bathing;  and  too  monotonous  a  diet.  Each  of  these  points  could 
be  enlarged  upon  with  profit.  For  example,  Andress  states  that  75 
per  cent,  of  the  country  dietaries  examined  were  deficient  in  milk, 
eggs,  butter,  vegetables  and  meat ;  in  fact,  deficient  in  the  very  prod- 
ucts raised  in  those  localities ! 

That  the  other  conditions  are  due  to  ignorance  rather  than  pov- 
erty is  shown  by  the  large  number  of  really  substantial  rural  houses 
which  have  dark,  water-holding  cellars,  dark  rooms,  and  inadequate 
ventilation.  Superstitions  last  longer  in  the  more  conservative 
country  districts,  and  adequate  night  ventilation  is  not  common.  A 
sanitary  investigation  of  four  whole  counties  in  Indiana  showed  very 
poor  conditions  throughout  the  entire  area.  Andress  states  that 
"  the  county  having  the  highest  average  score,  had  these  individual 
scores  on  the  ten  points  considered:  (1)  site,  73  per  cent.;  (2) 
sanitary  condition  of  premises,  68  per  cent.;  (3)  house,  68  per 
cent.;  (4)  cellar,  31  per  cent.;  (5)  ventilation,  14  per  cent.;  (6) 
water  supply,  15  per  cent.;  (7)  sewerage  disposal,  32  per  cent.; 
(8)  barnyard,  55  per  cent.;  (9)  disposal  of  manure,  22  per  cent.; 
(10)  health,  29  per  cent. 

School  Conditions. — Eural  schools  are  also  very  far  below  the 
standards  which  healthy  living  demands.     In  this  same  State  a 
census  of  seventy-five  rural  schools  yields  the  following  facts : 
0  had  fire  apparatus  of  any  kind. 
4  per  cent,  only  had  sanitary  drinking  fountains. 

75  per  cent,  used  a  common  wash  basin. 
9  per  cent,  only  had  adjustable  desks. 

14  per  cent,  only  of  the  boys  (41  per  cent,  of  the  girls)  used 
tooth  brush  daily. 

75  per  cent,  had  a  questionable  water  supply  (shallow  wells^ 
etc.). 

In  some  localities  the  conditions  are  still  worse.  In  the  South, 
for  example.  Stiles  has  estimated  that  68  per  cent,  of  the  rural 
sohoolhouses  have  no  privies  whatever — ^the  widely  contaminated  soil 
aiding  greatly  in  the  direct  transfer  of  hookworm  (Fig.  44)  through 


852 


HOME  AND  COMMUNITY  HYGIENE 


the  skin,  bare  feet,  etc.;  the  same  is  true  of  more  than  half  of 
nearly  200,000  homes  investigated. 

How  important  the  school  conditions  are  in  considering  these 
rural  questions  is  clear  when  we  read  Miss  Carney's  estimate  that 
'[  there  are  to-day  twelve  million  country  children  in  the  one-teacher 
rural  schools  of  the  United  States." 

Medical  Aid  Inadequate. — The  lack  of  medical  aid  in  rural 
regions  is  another  great  predisposing  factor.  Doctors  have  to  travel 
great  distances.  Dental,  eye  and  ear  clinics  are  not  available. 
School  nurses  and  school  doctors  are  almost  unknown.  Even  where 
defects  are  recognized,  attention  is  postponed  until  the  annual  visit 
to  the  city,  or  "  some  more  convenient  time,"  often  indefinitely. 

How  poorly  the  rural  child  fares  is  shown  when  compared  with 
the  opportunities  open  to  the  city  child. 


City  children 


Rural  children 


Medical  inspection  prac- 
tised 
Dental  inspection 

Dental  clinics 

Eye,  nose,  ear  clinics .  . 

Nurses 

Open  air  classes 

Warm  lunches 


In  over  400  cities In  parts  only  of  but  130 

counties  in  13  States 

69  cities |  Permitted  but  not  pro- 
vided in  2  States 


50  cities 

Cities  only 

135  cities 

Cities  only 

In  over  90  cities  in  21 
States 


1  rural  county 
None 

In  20  rural  districts 
None  reported 
In   a   few   schools   of 
States 


Plea  for  Improved  Conditions. — Conditions  indicate  that  the 
cities,  with  their  health  boards,  free  clinics,  medical  inspectors,  and 
public  health  education  movements,  are  constantly  improving  their 
sanitary  conditions  and  the  health  of  their  communities.  Figure 
103  shows  that  country  conditions  are  not  growing  much  worse,  but 
that  city  conditions  are  constantly  growing  better,  much  better. 
Why  should  not  the  country  people  have  the  advantages  of  our 
present  bacteriological  and  sanitary  knowledge  ?  What  can  be  done 
to  bring  the  rural  community  up  to  its  health  possibilities  ?  How 
great  is  the  problem  is  shown  by  Miss  Carney's  statement  that 
"notwithstanding  the  growth  of  cities  and  the  emigration  of 
country  people  to  urban  centres,  which  has  characterized  American 
life  during  the  past  quarter-century,  one-third  of  our  population 
still  lives  upon  the  land  and  follows  farming  as  a  vocation." 


RURAL  AND  URBAN  CONDITIONS  353 

Schools  Alone  Cannot  Solve  Rural  Problems. — The  same 
author  shows  how  difficult  it  is  to  meet  the  situation  through  our 
present  educational  system : 

"  Not  only  the  magnitude  of  the  problem,  but  also  the  neglect 
and  backwardness  of  rural  educational  conditions,  constitute  a 
strong  appeal  for  attention.  There  are  to-day  twelve  million  country 
children  in  the  one-teacher  rural  schools  of  the  United  States, 
taught  by  350,000  rural  teachers.  More  than  one-third  of  this 
great  army  of  country  teachers  has  had  no  professional  preparation 
whatever,  and  thousands  are  but  seventh  and  eighth  grade  gradu- 
ates, without  even  a  high  school  training.  Salaries  for  rural  teachers 
are  correspondingly  low,  ranging  in  general  from  $320  to  $540  per 
year.  All  education  still  suffers  from  a  lack  of  professionalism  and 
financial  return,  but  in  these  respects  rural  education  is  especially 
handicapped.  Even  in  its  administrative  and  supervisory  aspects 
rural  education,  unlike  urban  education,  is  not  yet  standardized. 
Practically  all  of  the  2500  county  superintendents  in  the  United 
States  are  still  chosen  through  an  archaic  and  pernicious  system  of 
political  election,  which,  for  the  most  part,  demands  no  professional 
requirements  of  candidates  before  selection,  and  provides  no  ade- 
quate compensation  for  their  retention  and  advancement  afterward. 
In  all  matters  of  general  administration,  as  in  questions  of  taxation 
areas,  building  standardization,  teacher-training,  supervision,  text- 
book supply,  health  control,  and  others,  country  schools  usually  re- 
ceive less  consideration  than  city  schools,  and  consequently  suffer 
the  more  surely  from  neglect.^' 

Much  will  doubtless  be  accomplished  by  the  publications  of  the 
Committee  on  Health  Problems  of  the  ISTational  Council  of  Educa- 
tion, "Minimum  Health  Eequirements  for  Eural  Schools"  and 
"Health  Essentials  for  Eural,  School  Children."  But  still  more  is 
hoped  for  through  their  Health  Charts,  several  of  which  are  reprinted 
in  this  chapter  (Figs.  103,  105,  and  106).  What  must  be  done  is 
indicated  by  these  same  charts.  There  is  no  reason  why  the  "  little 
red  schoolhouse  "  should  not  be  all  that  any  schoolhouse  could  ever 
be  (Fig.  106). 

The  health  of  the  people  is,  obviously,  the  one  great  asset  of  any 
country.  Eecent  school  investigations  and  the  revelations  of  the 
present  draft  concerning  physical  defects  have  made  people  feel  the 
need  of  a  fairer  and  more  general  distribution  of  the  opportunity 


354 


HOME  AND  COMMUNITY  HYGIENE 


HEALTH  DEFECTS 

City  Children  and  Country  Children  Compared 
Percentage  Averages  of  All  Available  Statistics 


i.es 
El  larked  Glands 


'■''   ^ai[  Defect; 
Breathing  De 


fects 
Curvature 


KEY 


eity 


Prepared  by  Df.  Thomas  D.  Wood,  515  Weil  I  joth  Street 
New  York  Cit).    1918 


Committee  on  Health  Problems  of  National  Council  of  Education 
and  American  Medical  Association 


Fig.  105. — Is  your  school  record  as  poor  as  this  ? 


RURAL  AND  URBAN  CONDITIONS         355 

NATIONAL  WELFARE  AND 
RURAL  SCHOOLS 

Country  children  are  less  healthy 
than  city  children 

City  standards  of  living  are  more 
healthful  than  those  in  rural  regions 

National  welfare  depends  upon 
the  health  of  the  people 

National  preparedness  depends 
primarily  upon  biologic  fitness  and 
physical  efficiency 

Country  children  deserve  as  much 
health  and  happiness  as  city  children 

Country  children  are  entitled  to 
as  carefiil  cultivation  as  crops  and 
live  stock 

The  rural  school  is  the  way  to 
improvement  of  health  of  country 
children  and  of  rural  life 

Pfepsrsdby  Dr.  TJiomas  D.  Wood,  5JS  West  lioA  Strert  Committee  on  Health  Problems  of  National  Council  of  Education 

New  York  City.    1918  and  American  Medical  Association 


FlQ.  106.— Can  you  think  of  some  way  of  driving  theae  facte  home? 


356 


HOME  AND  COMMUNITY  HYGIENE 


described  first  by  our  forefathers  among  our  inalienable  rights — 
for  life  "without  health  means  neither  liberty  nor  the  pursuit  of 
happiness.  It  is  to  be  hoped  that  the  federal  government  will  find 
some  way  to  secure  to  the  scattered  rural  population  fuller  oppor- 
tunity for  healthful  living. 

PROBLEMS 

1.  Military  leaders  say  that  city-bred  boys  are  more  easily  trained, 
less  susceptible  to  communicable  diseases  ( e.g.,  measles ) ,  and  of  higher 
technical  value  in  war;  after  the  first  year  or  two  of  training,  country-bred 
boys  are  found  to  be  better  soldier  material.     Can  you  explain  this? 

2.  The  "old  oaken  bucket"  is  used  in  open  wells,  subject,  Brewer  says, 
to  all  the  filth  that  blows,  rolls,  or  falls.  What  other  picturesque  associa- 
tions of  rural  life  must  go? 

3.  Fill  out  the  other  two  columns  for  the  topics  listed  below,  showing 
the  advantages  and  disadvantages  of  city  and  rural  life  with  regard  to 
each.  How  many  vary  with  the  housekeeper  or  the  individual  rather  than 
the  localitv  itself? 


aty 


fresh  air 

.sunshine 

simple  foods 

monotonous  diet 

hours  of  sleep 

exposure  to  weather 

lack  of   (mental  or  social  recreation' 

2JOor  ventilation 

medical  care 

poor  drinking  water 

transfer  of  communicable  diseases 


Country 


4.  What  can  rural  districts  do  with  the  materials  at  hand  to  attract 
better  teachers?  What  can  they  do  to  offset  city  salaries,  e.g.,  building 
little  log  bungalows  for  teachers'  homes,  providing  horses  or  vehicles  for 
recreation  ? 

5.  Can  your  rural  district  organize  a  traveling  clinic  for  teeth,  eyes, 
baby  care,  or  whatever  is  most  needed  for  your  community  and  adjoining 
ones?  Eighteen  hundred  dollars  a  year  would  doubtless  secure  a  young 
dentist  or  physician;  if  six  communities  joined  together  this  would  mean 
but  $.300  a  year  for  each  community.  Would  it  be  worth  $6  a  week  to  your 
community?     A  small  fee  could  be  collected  from  each  patient,  if  advisable. 

6.  Secure  from  the  nearest  large  city,  such  as  Xew  York  or  Chicago, 
a  set  of  the  regulations  concerning  examinations  and  licenses  for  eating 
houses,  food  handlers,  slaughter  houses,  and  stores  or  markets.  How  many 
can  you  put  into  operation  in  your  own  community  ? 

7.  When  a  farm  family  moves  into  the  city  what  new  conditions  do 
they  find  which  aid  in  health  protection?  To  what  conditions  must  a  city 
family  give  special  thought  or  care  if  they  "go  back  to  the  land"? 

8ee  Reference  List  at  end  of  Appendix. 


CHAPTER  XXIV 
VITAL  STATISTICS 

In  any  •well-organized  community  each  resident,  usually  appears 
several  times  by  name  in  its  public  records.  This  statement  does 
not  refer  to  the  various  military,  political,  or  other  civil  records 
necessary  to  govern  the  country  and  to  insure  to  each  inhabitant  his 
property  and  other  civil  rights.  People  not  holding  office,  not  own- 
ing property,  and  not  having  the  privilege  of  voting  do  not  appear 
in  the  latter  records;  but  they,  as  well  as  all  other  residents,  do 
appear  in  what  may  be  termed  the  vital  records — the  records  of 
births,  deaths,  etc. 

Each  person  is  quite  sure  of  appearing  twice  in  such  records — 
once  in  the  registry  of  births  and  once  in  the  death  records  (death 
certificates,  burial  permits).  All  who  reach  maturity  may  appear 
also  in  several  other  public  records:  the  population  records,  popu- 
larly termed  "  the  census,"  the  reports  of  communicable  diseases, 
and  the  marriage  records. 

General  Value  of  Vital  Statistics. — ^The  above  records  are 
valuable  in  several  ways;  for  example,  the  birth  registrations  may 
be  used  to  establish  a  child's  parentage,  a  man's  voting  age,  or  one's 
rights  to  property.  These  records  have  distinct  hygienic  value  also : 
First,  as  indications  of  the  nation's  strength  as  shown,  for  example, 
by  a  low  morbidity  (illness  and  disease)  rate,  by  deferred  death  ages, 
and  by  a  normal  increase  in  legitimate  births  when  accompanied 
by  low  infant  mortality  rate.  See  also  in  this  connection  Fig.  107. 
Second,  they  are  valuable  as  indications  of  what  the  community 
should  do  to  improve  the  nation's  strength,  and  largest  asset,  the 
health  of  its  people.  This  is  evident  when  such  records  are  worked 
over,^  and  sorted  according  to  significant  details,  such  as  the  num- 

^  In  some  cities  where  elaborate  records  are  kept,  the  cards  are  punched 
in  appropriate  places  to  record  the  dates,  the  name  of  the  disease,  the  sex 
of  the  individual,  etc.  These  may  be  sorted  rapidly  by  machinery,  the 
sortinsT  machine  being  set  to  catch  a  given  perforation  in  the  passing  cards. 
In  that  "way,  for  example,  all  the  ages  under  5  may  be  quickly  sorted  out; 
the  machine  can  then  be  reset  to  sort  out  all  of  these  children  dying  of  a 
given  disease,  or  all  not  vaccinated,  etc. 

357 


35g 


HOME  AND  COMMUNITY  HYGIENE 


ber  dying  from  a  given  ijreventable  disease,  or  the  victims  of  a 
dangerous  occupation.  In  such,  summarized  records,  the  individ- 
ual does  not  appear  by  name — simply  as  one  of  the  group  under 
consideration. 

,  Methods  of  Presenting. — ^When  such  records  are  worked  over 
for  publication  or  comparison,  it  is  usual  to  report  the  results  in 
percentages  or  in  proportion  to  a  given  unit  of  population;  the 
common  units  are  a  thousand  and  ten  thousand,  though  one  hundred 
thousand  is  not  uncommon.  If  the  percentages  in  each  group  are 
large  throughout,  the  familiar  per  cent,  basis  may  be  used;  "30 


•875 

;875 

I8S3 

1887 

1891 

1895 

1699 

1903 

1907 

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Fig.  107. — Birth  and  death  curves  for  Massachusetts  from  1871  to  1911.  Is  there 
any  period  where  the  relation  of  births  and  deaths  as  given  (per  1000)  would  mean  a  decrease 
in  population? 

per  cent,  of  the  children  are  anaemic,"  for  example.  But  if  the 
ratios  are  low,  but  a  part  of  a  per  cent.,  it  is  better  to  use  the  larger 
unit  of  1000,  10,000,  or  100,000 ;  thus  an  industrial  death  rate  of 
,01  per  cent.,  or  one-hundredth  of  1  per  cent,  means  but  part  of  an 
dividual  and  so  means  nothing  at  all  to  most  people.  But  expressed 
in  the  10,000  unit,  .01  per  cent,  becomes  one  person  in  every  10,000, 
a  whole  real  man,  for  example,  who  might  still  be  alive  if  a  safety 
brake  had  been  in  use. 

In  popular  articles,  the  conditions  are  often  made  still  more 
graphic.  A  typhoid  rate  of  thirteen  per  thousand  for  a  given  city 
of  80,000  is  not  nearly  so  alarming  as  is  the  total,  1040  per  year,  or 
20  every  week. 


VITAL  STATISTICS  359 

Careless  or  prejudiced  workers  sometimes  justify  the  joking 
classification  of  statistics  as  tlie  third  and  worst  class  of  lies;  e.g., 
small  groups  may  be  given  equal  rank  with  larger  groups/  and  the 
result  may  be  unduly  alarming  or  falsely  reassuring.  On  the  whole, 
however,  the  reports  issued  by  boards  of  health  and  other  investi- 
gators are  worthy  of  the  people's  trust. 

All  statistics  are  not  based  on  total  population  units.  A  large 
mining  camp  containing  but  two  or  three  children  might  be  credited 
with  a  low  infant  mortalit}',  even  though  all  of  its  children  died,  if 
their  deaths  were  compared  with  total  population.  It  is  fairer — 
more  indicative  of  the  actual  conditions — to  compare  such  actual 
deaths  with  the  possible  deaths ;  and  we  therefore  base  infant  mor- 
tality- rates  for  a  given  year  on  the  infants  born  that  year. 

Similarly,  changes  in  the  total  population  depend  not  only  on 
the  difference  between  the  birth  and  death  rates,  but  upon  the 
migration  of  large  masses  of  adults,  e.g.,  laborers,  military  bodies. 
In  the  same  way  comparisons  of  the  birth  rates  in  various  States 
are  not  fair,  unless  the  basis  of  comparison  includes  the  number  of 
married  women,  and  also  the  women  of  child-bearing  age.  Cancer 
statistics  should  be  based  on  the  number  of  cancer  age  (p.  301),  not 
on  the  population. 

Collection  of  Vital  Statistics. — Vital  statistics  are  collected  in 
two  main  ways:  (1)  singly,  as  the  events  occur  (births,  marriages, 
deaths)  ;  or  (2)  by  an  organized  enumeration  or  census.  The  latter 
may  be  taken  as  our  recent  registration  of  men  of  military  age  was 
conducted — by  having  all  the  individuals  report  to  assigned  stations 
within  a  given  period.  Lists  of  eligible  voters  are  usually  made  up 
in  that  way.  The  national  census  and  city  or  State  censuses  are 
made  by  a  house-to-house  canvass.  Each  method  has  its  own  diffi- 
culties, and  wholly  accurate  records  are  probably  not  attainable  in 
either  way  in  any  country  not  overofficialed. 

*  To  illustrate.  For  three  adjoining  localities  the  death  rate  for 
typhoid  was  as  follows:  1  in  15,  25  in  453,  and  76  in  52,427  total 
deaths.  For  the  whole  region  one  result  would  be  obtained  by  adding 
all  the  results,  giving  a  total  of  102  typhoid  deaths  in  a  grand  total  of 
52,895  deaths,  or  a  typhoid  rate  of  1.9  per  1000.  Another  result  would  be 
obtained  by  considering  the  various  ratios;  in  the  iirst  it  is  1:15,  or  66  per 
1000;  in  the  second,  about  1:18,  or  55  per  1000;  and  in  the  third,  about 
1:689,  or  1.4  per  1000.  If  we  consider  these  ratios  as  equally  important,  we 
have  a  death  rate  of  122.4  per  3000,  01:40.8  per  1000  instead  of  1.9  per  thou- 
sand obtained  by  the  other  method. 


360 


HOME  AND  COMMUNITY  HYGIENE 


Details  Included. — Many  diSerent  details  are  included  in  most 
of  these  statistical  records  (Figs.  108  and  109),  especially  in  the 
more  advanced  States.  The  population  census,  for  example,  includes 
about  twenty-five  details,  such  as  age,  sex,  color  or  race,  married  or 
single,  number  of  children,  nationality  of  parents,  native,  natural- 


i?  .s 


I  £ 

I/)  «| 

a  «  ° 
12? 


PLACE  OF  BIRTH 

County  of 

Township  of — 

or 

Village  of 

City  of 

FULL  NAME  OF  CHILD-.. 


DEPARTMENT  OF  COMMERCE 

BUREAU  OP  THE  CENSUS 

STANDARD  CERTIFICATE  OF  BIRTH 

State  of ~ 

Registered  No. 


....  st.j  Wart 


Twin,  triplet,  Numlwr  In  order 

or  other?  |      of  birth 

fTo  be  answered  orAy  In  event  of  plonil  births) 


Date  of 
birth — -_—--.. 

(Month) 


FULL 

MAIDEN 

NAME 


RESIDENCE 


RESIDENCE 


AOE  ATLAST 


BIRTHPLACE 


BIRTHPLACE 


OCCUPATION 


OCCUPATION 


tjumbcr  of  children  born  t 


I  mother,  Including  present  bMh  . 


Number  of  children  of  this  mother 


<  living.. 


CERTIFICATE  OF  ATTENDING  PHYSICIAN  OR  MIDWIFE* 

(BoixriEVVi^'EEuffiorn)" 


I  hereby  certify  that  I  attended  the  birth  of  this  child,  who  was ,- 

on  the  date  above  stated. 

(Signature)  - 


idwife,  then  the  father,  householder.  I 

(etc.,  should  make  this  return.  A  atillbom> 
child  it  one  that  neithrr  breathea  norshowt  I 
other  evidence  of  Ufe  afterbirth.  I 

Civen  name  added  from   a  supplemental      Address- 
report- |19 


(Phyeldsn  or  UidwUe) 


,  19 

11—335 


Fig.   108. — Standard  birth  certificate  issued  by  the  Public  Health  Service. 


ized  or  alien,  occupation,  ability  to  read  and  write,  and  ownership 
of  property,  including  also  certain  physical  defects  {e.g.,  blindness). 
Errors. — Errors  in  such  records  are  to  be  expected.  Misstate- 
ments concerning  age  make  a  large  proportion  of  these :  often  the 
date  of  birth  is  not  known ;  old  people  grow  old  more  rapidly  than 


i.  9  a. 

.S   ■  3 
«.  'O  U 

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goo 

£    «    0 

>W  e 

"o| 


■^^^  ■ 

Z  r"  o 

<  111  a    . 
S- o5 

111  Ti~  Si 

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A  111  —  o 

Z  S  o  ! 
S  <  X  g 

O    .  o  5 

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—  *  -  2 

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t    3    O  ~ 
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J  •»<  I 

■J   o  "^   m 

u  ,  u  J2 

H   o  W  2 

III*  ^o 


TI5 


STANDARD  CERTIFICATE  OF  DEATH 


1  PLACE  OF  DEATH 
County -. 

Township — 

City — - 


State Registered  No. 

or    Village — — — - or 

No ,  - _ - - St., Ward 

(If  death  occun-ed  in  a  hospital  or  instltutioa,  give  its  name  instead  o[  street  and  number) 


2  FULL  NAME..- _ — .. 

(a)  Residence.    No.  — 

(Usual  place  of  abode) 
Length  oF  residence  In  city  or  town  where  dsath  occurred 


.  St., Ward 

(If  nonresident  give  city  or  tov/n  and  State) 
!■       How  long  In  U.  S.,  If  of  foreign  birth? yrs^ moS; ds. 


PERSONAL  AND  STATISTICAL  PARTICULARS 


5a  If  married,  widowed,  or  divorced 
HUSBAND  bf 
(or)  WIFE  of 


6  DATE  OF  BIRTH  (month,  day,  and  year) 


If  LESS  than 
I  day, —  hrsi 
0^ —  mln. 


8  OCCUPATION  OF  DECEASED 


(b)  General  nature  of  Industryf 
business,  or  establishment  In 
which  employed  (or  employer)  - 
(c?  Name  of  employer 


9  BIRTHPLACE  (city  or  town) . 
(State  or  country) 


10  NAME  OF  FATHER 


11  BIRTHPLACE  OF  FATHER  (city  or  town)  . 
(State  or  cotmtry) 


12  MAIDEN  NAh/IE  OF  (MOTHER 


13  BIRTHPLACE  OF  MOTHER  (city  or  town)  . 
(State  or  country) 


Informant- 
(Address) 


MEDICAL  CERTIFICATE  OF  DEATH 


16  DATE  OF  DEATH  (month,  day,  and  year) 


I   HEREBYOERXIFYjThatl  attended  deceased  from 


.19-. 


,to- 


,19- 


that  I  last  saw  h alive  on — .  19 

and  ttiat  death  occurred,  on  the  date  stated  above,  at — m. 

The  CAUSE  OF  DEATH*  was  as  follows: 


.  (duration) ---  yrs.  - -.  mos. 


IS  Where  was  dj: 

If  not  at  place  of  death  ?-. 


Did  an  operation  precede  death? -  Date  of 

Was  there  an  autopsy? — 

What  test  confirmed  diagnosis? - — 

(Signed) -,M,  D. 

,19     (Address) 


HoMcmAl,".    (See  reverse  side  for  ad!ditional  space.) 


19  PLACE  OF  BURIAL  CREMATION,  OR  REMOVAL     DATE  OF  BURIAL 


20  UNDERTAKER 


FiQ.    109. — Standard  death  certi6cate  issued  by  the  Public  Health  Service. 


VITAL  STATISTICS  361 

the  passing  of  time  warrants;  many  people  forget  their  ages;  and 
records  always  show  an  excessive  number  of  people  at  certain  stand- 
ard ages  {&.g.,  fort}^,  sixty-five).  Occupation  is  another  uncertain 
item,  mainly  because  the  descriptive  terms  for  work  do  not  include 
all  the  present  manifold  forms  of  labor;  e.g.,  manager  may  mean 
either  a  desk  or  an  outdoor  position.  Conclusions  as  to  occupational 
predisposition  to  disease  would  be  affected  by  such  broad  or  vague 
terms.  The  mortality  rates  for  certain  occupations  are  not  to  be 
fairly  estimated  by  such  records :  someone  has  illustrated  this  by 
showing  that  newsboys  have  a  very  low  mortality  rate  when  com- 
pared with  bank  presidents,  not  because  the  newsboy  business  is  a 
very  safe  or  protected  one,  but  because  newsboys  are  young  and  bank 
presidents  are  old,  because  they  are  selected  from  the  older  experi- 
enced men. 

The  very  human  tendency  to  procrastinate  is  responsible  for 
other  errors,  especially  in  birth  registrations.^  In  certain  cases 
such  lack  of  responsibility  may  be  partly  neutralized  by  preliminary 
permits ;  e.g.,  a  marriage  license  is  usually  required  before  the  mar- 
riage ceremony  can  be  performed,  a  death  certificate  must  usually 
be  presented  to  secure  a  burial  permit,  without  which  the  body  can- 
not be  buried,  removed  to  another  place,  etc.  Such  measures  pre- 
vent deception,  and  help  to  detect  and  keep  down  crime.  While 
there  are  in  some  States  fines  or  other  penalties  for  delaying  or 
omitting  registrations,  carelessness  in  such  matters  is  rarely  penal- 
ized except  in  the  case  of  deaths.  The  United  States  authorities 
consider  the  death  reports  for  the  registration  area  of  the  country 
at  least  90  per  cent,  correct.  The  full  co-operation  of  the  States  has 
not  been  obtained  as  yet;  the  reliable  or  '^ registration  area"  in- 
cludes but  twenty-six  States  and  parts  of  thirteen  others.  The  im- 
portance of  such  records  should  be  emphasized  by  civic  and  State 
authorities  in  such  a  way  that  the  co-operation  of  the  people  can  be 
secured. 

There  are  probably  yet  untried  ways  of  securing  more  complete 
records.    Colored  cards  might  be  provided  by  each  city,  county,  etc., 

^  In  some  other  countries  the  prompt  recording  of  such  statistical  re- 
ports is  enforced  much  more  severely.  An  American  family  who  happened 
to  be  in  Germany  Avhen  a  daughter  was  born,  delayed  for  a  few  days  the 
prescribed  regulations,  because  the  family  could  not  decide  upon  a  name. 
The  father  was  forcibly  taken  to  court  and  detained  there  until  he  decided 
upon  a  name. 


362  HOME  AND  COMMUNITY  HYGIENE 

a  different  color  for  each  type  of  record  {e.g.,  births,  notifiable 
diseases).  These  might  be  left  in  specially  provided  racks  in  all 
public  places  (churches,  schools,  police  offices,  post  offices,  etc.),  and 
in  common  carriers  (railroad  trains,  street  cars),  and  halls  of  apart- 
ment houses,  and  large  commercial  offices.  Individuals  knowing  of 
a  suspicious  death,  an  a/s  yet  unquarantined  house,  or  an  unregis- 
tered birth  could  fill  in  one  of  these  addressed  cards  and  mail  (with- 
out postage).  If  protection  were  assured  the  sender,  and  attention 
paid  to  only  fully  signed  cards  (with  sender's  address,  occupation, 
etc.),  this  might  prove  a  good  system  of  checking  up  on  the  reports 
sent  in,  and  insuring  greater  accuracy  and  completeness. 

There  is  still  another  class  of  mistakes  which  are  probably  un- 
avoidable, but  which  limit  the  hygienic  importance  of  such  records. 
The  causes  of  death  are  often  incorrectly  stated,  sometimes  for 
illegal  reasons  or  to  hide  crime,  but  more  often  because  of  the  diffi- 
culties of  diagnosis  experienced  by  even  good  physicians.  Even  in 
hospitals  (where  the  opportunities  for  correct  diagnosis  are  usually 
good)  many  errors  appear,  and  autopsies  show  that  in  one  set  of  over 
three  thousand  patients  there  were  many  incorrect  reports;  liver 
and  kidney  diseases,  for  example,  could  boast  but  16  to  39  per  cent, 
of  accurate  reports,  though  many  other  diseases  were,  of  course,  well 
reported  {e.g.,  typhoid,  92  per  cent,  correct).  It  is  often  difficult 
to  give  one  definite  cause  of  death;  to  meet  this  difficulty  certain 
rules  are  established  to  guide  when  there  is  a  "  complication  of  dis- 
eases." The  preference  is  given  to  the  frequent  over  the  infrequent, 
to  the  one  most  often  fatal,  to  the  primary  disease,  etc. 

Community  Rights. — The  value  of  morbidity  statistics  (this 
includes  death — ^mortality — and  also  illness)  has  not  been  widely 
recognized  as  yet.  It  is  just  as  important  for  a  country  to  know 
the  per  cent,  of  effective  people  as  it  is  to  know  the  per  cent,  of 
people  not  yet  actually  dead. 

Each  day  of  illness  is  an  economic  loss  to  any  productive  citizen, 
and  may  also  affect  his  general  vitality  sufficiently  toi  lessen  his  ex- 
pectation of  life.  Then,  too,  communicable  diseases,  if  not  reported, 
may  spread  rapidly  and  become  directly  a  community  problem  (see 
p.  310). 

Other  Values  of  Vital  Statistics. — As  "municipal  bookkeep- 
ing "  vital  statistics  are  most  important.  There  is  no  clearer  way 
of  showing  a  community  just  where  it  stands.     In  a  period  of  about 


VITAL  STATISTICS 


363 


ten  years  Jersey  City's  typhoid  death  rate  fell  from  61  per  100,000 
to  19 ;  in  the  same  period  Pittsburgh's  rose  from  61  to  120  !  Could 
anything  justify  more  fully  Jersey  City's  expenditure  of  money  in 
treating  the  river  water  it  was  using  for  drinking  purposes,  and 
could  anything  make  it  clearer  to  Pittsburgh  that  such  expenditure 
was  necessary  ? 

Occupational  diseases  are  reportable  in  but  seven  to  fourteen 
States,  more  or  less  completely.    In  the  last  draft  over  60  per  cent. 


Tnim   mfioi 


90% 


QO^^ 


70^ 


J0% 


9.9^    jRqfl   ms\ 


/v 


jm 


IM   1910. 


■s. 


Fig.  110. — The  heavy  line  near  the  top  (100  per  cent.)  represents  the  expected  mor- 
tality; the  line  beginning  in  the  upper  left-hand  square  gives  the  ratio  of  deaths  among 
non-abstainers  from  alcohol;  the  lower  line  shows  the  ratio  of  deaths  among  abstainers. 


of  the  factory  youth,  according  to  the  head  of  a  large  industrial 
union,  failed  to  pass  the  physical  examinations.  The  large  number 
of  still-births  among  women  employed  in  industrial  occupations 
also  illustrates  the  hitherto  unguessed-at  relation  between  health 
and  occupation,  and  shows  clearly  the  community's  responsibility. 
More  general  interest  in  vital  statistics  would  increase  the  "  reg- 
istration area."  Still  more  would  it  help  secure  complete  records  of 
all  required  data  in  the  registration  area.  "  Too  great  individual- 
ism "  explains  part  of  this  lack;  but  part  of  it  is  tied  up  with  what 
is  commonly  termed  physician's  honor.    There  is  the  greatest  reason 


364  HOME  AND  COMMUNITY  HYGIENE 

in  the  world  for  respecting  the  general  principle  which  demands 
that  physicians  keep  inviolate  knowledge  that  would  be  to  the  dis- 
advantage of  his  patient.  But  the  individual  rights  must  not  con- 
flict with  the  good  of  the  community  to  such  an  extent  that  he  can 
become  a  focus  of  infection.  This  reticence  is  felt  particularly  with 
regard  to  venereal  diseases.  Common  sense  says  that  there  is  little 
excuse  for  the  type  of  reticence  that  makes  a  physician  side  with  a 
client  when  speech  would  protect  ignorant  members  of  the  house- 
hold, or  prevent  the  birth  of  children  who  can  have  but  little  chance 
of  health  and  sanity.  There  is  little  doubt  that  physicians  gen- 
erally will  be  greatly  relieved  to  have  public  opinion  demand  the 
complete  and  full  recording  of  all  communicable  diseases.  And 
that  it  is  for  the  good  of  the  community  no  one  can  deny. 

The  value  of  such  statistics  has  been  recognized  by  various  com- 
mercial organizations,  and  tables  showing  the  expectation  of  life, 
and  how  it  is  affected  by  various  physical  characteristics  and  dis- 
abilities, by  occupation  and  by  such  habits  as  alcohol  and  smoking, 
are  the  basis  of  their  insurance  and  annuity  rates  (Fig.  110).  If 
they  have  proven  important  to  those  who  make  money  on  the  pro- 
longation of  our  lives,  why  are  such  records  not  sufficiently  impor- 
tant to  us  to  help  us  see  how  we  can  still  further  prolong  a  useful 
life  period  ?  Can  we  as  a  country  or  as  individuals  afford  to  neglect 
the  securing  of  complete  vital  records,  and  their  presentation  in 
usable  form? 

PROBLEMS 

1.  What  vital  statistics  are  compulsory  in  your  State? 

2.  What  items  of  value  are  not  included  in  the  birth  certificate  used 
in  your  locality  ?     In  the  death  certificate  ? 

3.  Give  reasons  or  instances  justifying  each  of  the  various  items  in  the 
birth  certificate  used  in  your  locality.  In  the  death  certificate.  In  the 
marriage  license. 

4.  Do  the  life  insurance  rates  vary  with  state  of  health?  alcoholic 
habits?  or  with  age  only?  If  the  rates  are  the  same,  who  really  pays  the 
extra  premium  for  people  who  are  poor  risks? 

5.  ^Vhat  physical  defects  are  most  common  in  the  students  of  your 
school?  What  per  cent,  of  these  are  preventable?  Has  your  State  any 
provision  for  remedying  these  conditions? 

6.  Show  that  the  recent  ruling  adopted  for  the  State  of  New  Jersey 
allowing  districts  to  spend  public  money  for  school  conveyances  for  crippled 
children  is  a  legitimate  expenditure  of  money. 

7.  What  is  the  most  common  cause  of  death  in  your  community?  Can 
this  be  explained?  What  per  cent,  of  deaths  in  your  town  are  due  to  con- 
tagious diseases? 


VITAL  STATISTICS  365 

8.  Make  birth  and  death  curves  for  your  town  for  the  last  five  years. 
How  does  this  agree  with  the  population  curve?  Explain  the  likenesses  or 
differences. 

9.  The  following  is  from  a  pamphlet  issued  by  the  New  Jersey  State 
Board  of  Health.    How  does  your  State  stimulate  interest  in  vital  statistics  ? 

Is  YouB  Baby  Registered? 
If  Not,  Why  Not?    Ask  Youb  Physician 

Your  baby  will  need  a  birth  record 

To  prove  his  riglit  to  go  to  school. 

To  prove  his  right  to  working  papers. 

To  prove  his  right  to  an  inheritance. 

To  prove  his  right  to  vote. 

To  prove  his  right  to  marry. 

To  prove  his  right  to  a  passport  when  travelling  abroad. 

To  secure  protection  in  foreign  countries. 

To  prove  his  mother's  right  to  a  widow's  pension. 

Prize  cattle  are  registered.  If  your  baby  is  a  prize  baby,  register  him;  if 
not,  be  sure  to  register  him  and  ask  your  physician  and  the  health 
authorities  how  to  make  him  a  prize  baby.     Do  it  now. 

10.  Fill  in  the  blanks  in  the  following 

statistics  are  the  statistics  of  life. 

Morbidity  statistics  are  the of  disease. 

statistics  are  the  statistics  of  death. 

Birth, and  migration  statistics  relate  to  population 

movement. 
Statistics  of  and  of  immigration  show  population 

increment. 
Statistics  of    and  of  emigration  show  population 

decrement. 

See  Reference  List  at  end  of  Appendix. 


CHAPTER  XXV 
'  HEALTH  EDUCATION 

Early  Movements  for  Health  Education. — One  of  the  first, 
if  not  the  first,  altruistic  movements  for  health  education  in  the 
United  States  was  Horace  Mann's  endeavor  to  introduce  the  study 
of  human  physiology  into  the  public  schools.  This  appeal  was 
not  made  until  in  1842,  so  slow  were  we  to  realize  that  health,  the 
one  great  asset  of  any  nation,  demands  as  well  as  deserves  conscious 
consideration. 

The  first  nation-wide  movement  related  to  health  was  the  cam- 
paign against  tuberculosis.  Infant  welfare  was  the  next  definite 
campaign  against  disease,  and  both  have  accomplished  marked  re- 
sults. In  regard  to  both  these  causes — tuberculosis  and  infant  wel- 
fare— it  is  well  to  remember  two  things:  (1)  That  they  have 
been  definite  campaigns  with  definite  ends  in  view,  and  (2)  that 
while  remarkable  results  have  been  attained  in  the  lives  actually 
saved,  the  greatest  value  to  us  as  a  nation  lies  elsewhere — in  demon- 
strating that  mere  curing  is  too  slow  a  method  of  combating  the 
evils  under  discussion,  that  better  results  are  obtained  by  preven- 
tion, that  conscious  and  intelligent  care  can  prevent  not  only  death 
but  illness,  and  that  predisposing  factors  can  be  controlled. 

Need  for  Health  Education. — How,  then,  is  this  movement  to 
be  made  a  general  movement?  How  can  the  principles  of  hygiene 
be  made  concrete  enough  to  appeal  to  all  the  people  ?  For  they  must 
be  so  concrete  that  they  appeal  to  all — even  to  the  stranger  within 
our  gates;  they  must  be  so  clear  that  even  the  wayfaring  man  may 
not  err  therein. 

Every  chapter  in  this  book  is  a  plea  for  health  education.  The 
standards  set  forth  and  the  evils  to  be  avoided  call  for  definite 
knowledge  on  the  part  of  each  individual,  for  expensive  and  sweep- 
ing innovations  are  demanded  which  must  be  supported  by  public 
sentiment.  Besides,  many  of  the  necessary  changes  or  desirable 
procedures  are  so  individual  that  only  by  securing  individual  re- 
sponsibility and  action  can  we  secure  the  desired  result  (Fig.  111). 

Without  education  concerning  health,  we  can  do  very  little. 
366 


HEALTH  EDUCATION  367 


INDICATIONS  of  HEALTH 
DISORDERS  in  CHILDREN 

For  which  parents  should  keep 

children  at  home  and 

notify  the  school 

Nausea  or  vomiting  Fever 

Chill,  convulsions  (fits)  Acutely  swollen  glands 

Eruption  (rash)  of  any  kind  Cough 

Red  or  running  eyes  Running  nose 

Sore  or  inflamed  throat  Failure  to  eat  the  usual  breakfast 

Dizziness,  faintness  or  unusual  pallor  falarming 
paleness  of  the  face) 

Any  disturbing  change  from  usual  appearance  or  conduct  of  child 

The  foregoing  signs  should  be  used  also  by  teachers  as  a  basis 

for  excluding  pupils  from  school  for  the  day,  or  until 

signs  have  disappeared,  or  until  the  proper 

health  officer  has  authorized  the  return 

of  the  pupil  to  school 


tnptnd  by  Dr.  Thoiiui  D.  Wood,  jij  Wat  no*  Street  CoDllhittce  on  Health  Problems  of  Nitional  Council  of  Edi 

New  York  City.    1919  and  Atncrican  Medical  Association 

Chart  4 

FiQ.  111. — This  demands  a  strong  sense  of  community  responsibility  as  well  as  consideration 
for  one's  own  children. 


368  HOME  AND  COMMUNITY  HYGIENE 

We  may  provide  free  cancer  hospitals,  but  they  are  of  little  use 
unless  people  realize  that  early  treatment  is  necessary;  milk  sta- 
tions probably  save  about  one-fifth  of  our  babies,  but  intelligent 
home  care  is  needed  to  insure  the  welfare  of  the  other  four-fifths. 
W^e  may  frame  model  housing  laws,  but  we  can't  legislate  that  a 
family  in  those  houses  shall  eat  the  proper  foods  or  sleep  with  open 
windows.  Health  education  is  necessary  also  in  order  to  secure  the 
proper  support  for  the  necessary  legislation  and  taxation.  Health 
officers,  school  nurses,  improved  water  supplies,  proper  methods  of 
sewage  disposal,  the  enforcement  of  quarantine,  and  free  diagnosis 
of  communicable  disease  cost  money,  and  public  approval  of  such 
expenditures  is  usually  necessary.  This  neces'sity  for  the  support 
by  the  taxpayers  and  voters  is  felt  most  directly  in  small  com- 
munities; in  large  cities  as  well  as  in  smaller  communities  it  often 
acts  as  a  curb  on  political  machines  which  would  prefer  to  deflect 
the  money  into  other  channels. 

Present  Educational  Systems  Inadequate. — Since  the  move- 
ment is  fundamentally  one  of  education,  the  schools  naturally  come 
into  our  minds.  As  Evans  has  stated,  the  public  schools  are  too 
slow.  We  must  wait  a  generation,  if  we  depend  wholly  upon  them. 
Quicker  results  would  be  obtained  through  our  higher  schools  and 
colleges.  Does  it  not  seem  unwise  to  give  the  care  of  our  children 
for  a  good  part  of  the  day  to  teachers  who  know  nothing  of  .human 
physiology?  Yet  many  of  our  normal  schools  give  no  instruction 
in  physiology  or  hygiene;  in  many  other  normal  schools  they  are 
not  considered  sufficiently  important  to  be  classed  as  separate  sub- 
jects, but  are  given  a  few  hours'  time  in  connection  with  gymnastics 
or  nature  study !  Colleges,  too,  forget  that  "  the  proper  study  of 
mankind  is  man,"  and  some  of  our  largest  and  best  known  colleges 
do  not  require  human  physiology,  hygiene,  or  bacteriology.  In 
some  of  them  such  courses  are  not  even  offered.  Clearly,  then,  we 
cannot  wait  for  the  schools,  though  there  are  encouraging  signs  that 
such  responsibilities  are  being  realized  even  by  the  most  conservative. 

General  Suggestions. — The  federal  government  has  under 
consideration  a  plan  for  introducing  throughout  our  public  school 
system  better  instruction  in  hygiene.  This  plan  is  not  yet  perfected, 
but  real  benefit  can  safely  be  expected  from  this  movement.  In 
the  meantime  we  must  utilize  any  cause,  interest,  or  movement  that 


HEALTH  EDUCATION  369 

axises.  We  must  not  wait  for  a  star,  but  must  hitch  our  wagon  to 
any  force  moving  in  the  right  direction. 

The  recent  war  was  a)  good  illustration.  How  will  the  millions 
of  soldiers  who  have  been  inoculated  (G-)  against  typhoid  weigh 
the  respective  values  of  prevention  and  cure?  Will  those  whose 
lives  depended  on  the  sanitary  provisions  carried  out  effectively  under 
difficulties  in  trench  life  feel  that  ordinary  localities  cannot  be  kept 
in  a  sanitary  condition?  Will  they  view  in  the  same  careless  way, 
as  formerly,  the  requirements  regarding  quarantine  and  disinfec- 
tion? Every  home,  every  street,  as  safe  as  the  trenches  is  not  ask- 
ing too  much.  The  emphasis  on  age  limits  in  the  war  can  be 
used  to  emphasize  the  value  of  vital  statistics  and  to  extend  the 
registration  area  (G),  for  such  statistics  as  birth  records  are  as 
necessary  for  the  patriotic  youth  seeking  to  enlist  as  for  a  govern- 
ment that  needs  to  compel  the  service  of  "  slackers.'' 

Every  locality  will  have  its  own  special  interests — ^temporary  or 
permanent — ^which  can  be  utilized  for  advancing  health  education. 
Civic  pride,  competitive  spirit,  can  be  used  as  a  lever.  Every 
Tacoma  has  a  Seattle,  probably,  and  what  better  totem  pole  than  a 
tree  of  life?  Civic  pride  could  be  used  to  help  maintain  many  a 
"  spotless  town."  The  school  often  makes  an  appeal  to  more  people 
than  any  other  one  community  interest.  The  aims  set  forth  in 
figures  112  and  113  can  be  taken  up  singly,  if  advisable. 

More  or  less  transitory  interests  can  be  utilized  to  further  the 
opportunities  for  health  education.  These  interests  may  be  most 
varied  in  range:  a  mosquito  summer,  food  poisoning  (Gr)  after  a 
grange  supper,  an  infantile  paralysis  epidemic,  or  a  political  cam- 
paign. Whatever  the  interest  that  vitalizes  the  movement,  the  cam- 
paign should  be  conducted  vigorously,  and  be  brought  in  style  to  its 
proper  conclusion.  The  workers  or  originators  should  have  defi- 
nitely in  mind  the  aim  of  the  movement :  e.g.,  forming  public  senti- 
ment or  securing  new  health  legislation.  Such  campaigns  will 
often  take  more  strategic  planning  than  political  campaigns,  for 
there  are  relatively  few  people  interested  both  unselfishly  and 
directly  in  improved  health  conditions. 

Attention  should  also  be  paid  to  the  permanency  of  the  reform. 
All  movements  for  the  public  good  should  be  established  "  with  per- 
petual care."  If  bills  are  passed  they  should  carry  an  annual  ap- 
propriation to  make  their  execution  possible.     If  ideals  or  stand- 


370 


HOME  AND  COMMUNITY  HYGIENE 


Ten  Sanitary  Commandments 
for  Rural  Schools 

In  every  school  whichinay  be  considered  passably 

sanitary  the  following  conditions 

shall  obtain: 


1.  Heating  by  at  least  a  properly 
jacketed  stove.  (No  unjacketed  stove 
to  be  allowed.)  Avoid  overheating. 
Temperature  should  never  go  above 
68F.  There  should  be  a  thermometer 
in  every  schoolroom.  Ventilation  by 
open  windows  when  weather  permits 
and  by  opening  of  windows  at  fre- 
quent intervals  even  in  winter 

2.  Lighting  from  left  side  Of  room 
(or  from  left  and  rear)  through  win- 
dow space  at  least  one-fifth  of  floor 
space  in  area 

3.  Cleanliness  of  school  as  g'ood  as 
in  the  home  of  a  careful  housekeeper 

4.  Furniture  sanitary  in  kind  and 
easily  and  frequently  cleaned.  Seats 
and  desks  adjustable  and  hygienic  in 
type 


^.  Drinking  water  from  a  pure 
source  provided  by  a  sanitary  drink- 
ing fountain 

6.  Facilities  for  washing  hands,  and 
individual  towels 

/^.  Toilets  and  privies  sanitary  in 
type  and  in  care  (with  no  cesspools 
unless  water  tight)  and  no  neglected 
privy  boxes  or  vaults 

o.  Flies  and  mosquitoes  excluded 
by  thorough  screening  of  schoolhouse 
and  toilets 

Q.  Obscene  and  defacing  marks 
absolutely  absent  from  schoolhouse 
and  privies 

10.  Playground  of  adequate  size  for 
every  rural  school 


Ptepsred  by  Di.  ThomM  D.  Wood,  515  Wesi  iiolh  Street 
New  York  City.    1918 


Committee  on  Health  Problems  of  National  Council  of  Edu 
and  Amencan  Medical  Association 


Fig.  112. — Minimum  standards  for  rural  schools. 


HEALTH  EDUCATION 


371 


Ten  Essentials  for  Health 

Care  of  Children  in 

Rural  Schools 


I.  Daily  health  inspection  by 
parent  and  teacher  with  the  co- 
operation of  school  nurses  and 
doctors 


2.  General  health  examination 
icluding  dental  ( 
least  once  a  year 


including  dental  examination  at 


3.  Follow  up  health  work  with 
provision  of  medical,  surgical 
and  dental  care  for  correction  of 
health  defects,  with  service  of 
school  or  district  nurse,  to  make 
effective  the  health  program  in 
the  school 

4.  Warm  school  lunches  for  all 
rural  scTiool  children 

5.  Sanitary  and  attractiveschool 
houses  and  surroundings 

6.  Efficiently  tramed  teachers 
who  are  qualified  to  do  their  full 


share  in  the  care  of  health  and 
welfare  of  the  children 

/.  Practical  health  instruction 
of  all  pupils  for  the  establishment 
of  health  habits  and  the  extension 
of  health  conduct  and  care  to  the 
school,  to  the  homes  and  to  the 
community  in  general 

o.  Special  classes  and  schools 
for  the  physically  and  mentally 
defective 

9.  Generous  provision  for 
wholesome  play  and  recreation 
in  school  and  community 

10.  Organization  and  cooperation 
of  interested  people  and  societies 
to  insure  to  all  the  children  the 
essentials  of  health  and  general 
well-being 


Prepared  by  D<.  Thomas  D  Wood,  515  Weil  120*  Snt« 
New  York  Ciiy     1918 


Commitree  on  Health  Problems  of  National  Council  oF  Education 
and  American  Medical  Association 


FiQ.  113. — Can  your  community  afford  to  disregard  any  one  of  these  essentials? 


372  HOME  AND  COMMUNITY  HYGIENE 

ards  are  developed,  they  should  be  established  by  the  selection  of 
virile,  interested  ofl&cers  or  committees. 

Extreme  statements  or  unsound  arguments  must  not  be  used  in 
working  up  such  a  campaign.  Impossible  standards  must  not  be 
set,  for  the  slump  which  inevitably  follows  will  be  difficult  to  over- 
come. 

Schools. — Even  though  we  can't  wait  for  children  to  grow  up, 
the  work  must  be  begun  and  carried  on  in  the  schools,  for  the  sake 
of  the  next  generation.  Much  spreads  directly  from  the  schools  to 
the  home,  and  such  campaigns  as  open-window  week,  clean-up  week, 
and  fly-killing  contests  have  good  effects.  Junior  health  officers 
have  been  tried  with  good  results  in  some  towns.  Their  work  need 
not  be  confined  to  the  school,  but  could  easily  include  many  phases 
of  community  health  work,  such  as  clean  streets,  refuse  or  garbage 
accumulations,  care  of  stables,  flies  and  rats  in  shops  and  markets. 

Other  Suggestions. — Organizations  already  in  existence  may 
be  utilized,  such  as  mothers'  clubs,  little  mothers'  clubs,  scout  or- 
ganizations, women's  clubs,  men's  mercantile  associations,  labor 
organizations,  and  civic  clubs. 

Fly  campaigns  may  be  utilized.  In  the  latter,  care  must  be 
taken  to  avoid  encouraging  dishonesty.  Offering  prizes  for  the 
largest  number  of  flies  collected  and  killed  has  led  to  the  breeding 
of  flies.  If  such  campaigns  were  conducted  for  but  a  brief  time — 
ten  days  or  less — the  time  would  be  too  short  to  allow  such  sharp 
practice  to  enter  in.  Wood  suggests  that  fly  campaigns  be  centered 
upon  the  breeding  places  rather  than  the  flies.  Still  better  is  the 
suggestion  of  "  no-fly  days,"  with  stores,  markets,  homes,  etc.,  all 
working  to  eliminate  flies  so  completely  that  July  4th  or  some 
other  day  shall  be  a  no-fly  day.  Girl  or  Boy  Scouts  might  be 
utilized  as  reporters  for  such  "  no-fly  days." 

Clean-street  competition  can  be  participated  in  by  the  whole 
community.  Scoring  stores  has  been  tried  by  several  cities.  The 
best  plan  seems  to  be  awarding  indicative  signs  {e.g.,  for  no  flies) 
or  certificates  to  all  passing  certain  minimum  standards,  such  as 
relate  to  flies,  cleanliness,  refuse. 

Exhibits. — Exhibits  have  been  a  favorite  method.  They  must 
attract  the  people  they  are  designed  to  help.  Baby-welfare  cam- 
paigns must  reach  the  foreigners  and  slum  residents  as  well  as  other 
citizens.     The  location  must  be  carefully  considered ;  it  is  some- 


HEALTH  EDUCATION 


373 


times  better  to  move  the  exhibit  to  various  localities,  adapting  it  to 
the  needs  of  each  locality. 

The  exhibits  must  be  simple,  clear  and  readable.  Too  many 
diagrams  confuse  most  people.  The  labels  should  not  be  too  long. 
The  individual  parts  of  the  exhibition  should  be  separated,  so  that 
interested  groups  may  study  at  leisure  those  they  find  interesting. 
Contrasts — good  and  bad;  before  and  after;  what  to  do  and  what 
not  to  do — are  most  easily  interpreted  and  assimilated.     Statistics 


rne 


"Bei  0  re 


■i 


fl;(rer 


Fig.   114. — What  can  be  done  to  help  people  who  would  rather  not  know  how  dirty  the 
milk  is,  the  unclean  way  in  which  typhoid  is  usually  transferred,  etc.? 

must  be  put  vitally ;  for  example,  intead  of  "  125/^  per  cent,  of  the 
deaths  are  due  to  cancer,"  use  "  1  in  8  dies  of  cancer." 

While  the  evils  to  be  corrected  must  be  made  concrete  and  real, 
the  tone  of  such  exhibits  must  not  be  morbid.  The  impossible  must 
not  be  set  as  a  standard.  The  terror  realized  must  be  a  terror  con- 
quered, as  shown  in  the  '^  before  and  after  "  illustration  (Fig.  114). 

The  United  States  Health  Service  and  several  of  the  States 
have  exhibits  which  may  be  borrowed  by  interested  communities 
Organizations  such  as  the  Children's  Bureau  at  Washington  and  the 
National  Mental  Hygiene  Society  in  New  York  City  are  very  gen- 
erous with  literature.    The  Child  Health  Organization,  New  York 


374  HOME  AND  COMMUNITY  HYGIENE 

City,  is  beginning  a  child-saving  campaign,  and  offers  advice,  litera- 
ture, and  even  local  surveys  at  cost  prices.  The  National  Child 
Welfare  Exhibit  Committee  of  New  York  has  good  exhibit  material. 
Some  State  health  departments  issue  each  week  a  series  of  timely 
articles,  such  as  "  Summer  or  Vacation  Typhoid " ;  "  Flies  Our 
Enemies  " ;  "  Water  and  Typhoid  Fever  " ;  and  "  Vaccination.^'  In 
1914  over  four  hundred  local  newspapers  were  using  such  articles 
issued  by  the  Few  York  State  Department  of  Health,  thus  reaching 
weekly  one  and  a  half  million  readers. 

PROBLEMS 

1.  Show  that  Lord  Derby  was  right  when  he  said,  "  Sanitary  instruction 
is  even  more  important  than  sanitary  legislation." 

2.  Arrange  in  order  most  needed  in  your  community  the  following  ac- 
tivities :  ( 1 )  investigation  of  the  infant  mortality  rate,  ( 2 )  of  the  indus- 
trial death  rate,  (3)  the  typhoid  rate,  (4)  sanitary  quality  of  milk,  (5) 
erection  of  a  city  pasteurizing  station,  (6)  a  garbage-disposal  plant,  (7) 
subsurface  drainage  for  the  school,  library,  church,  etc.,  (8)  filter  or 
storage  reservoirs  for  water,  (9)  fly-screens  for  the  schoolhouse,  and  (10) 
care  of  the  streets. 

3.  If  an  organization  in  your  town  had  $500  (or  $25)  to  spend  for 
public  health,  what  would  be  the  wisest  expenditure  of  that  money? 

4.  Show  that  it  might  be  wiser  to  spend  it  all  on  a  sanitary  survey  to 
portray  to  the  people  the  real  condition  of  affairs,  and  trust  to  securing 
from  them  when  awakened  the  money  necessary  to  correct  present  evils. 

5.  What  books  ( or  important  pamphlets )  on  public  and  personal  health 
are  in  your  public  library  (or  school  library)  ? 

6.  The  Carnegie  Corporation  is  now  starting  a  survey  of  the  American- 
ization of  our  foreign  population,  including  schooling  of  the  immigrant,  ad- 
justment of  home  and  family  life,  care  of  health,  naturalization  and  politi- 
cal experience,  treatment  of  immigrant  heritages,  neighborhood  agencies  and 
organizations  and  rural  developments.  Show  which  of  these  have  important 
relationship  to  health  education? 

7.  Some  newspapers  conduct  a  question  and  answer  column  on  per- 
sonal health.  Do  you  know  of  a  paper  that  conducts  a  similar  column  for 
public  health  and  sanitation? 

8.  Plan  the  details  of  a  community  Health  Week,  including  its  adver- 
tisements, exhibits,  speakers,  and  publications  for  distribution. 

9.  Recently  some  of  the  largest  "  chain  "  restaurants  have  been  printing 
the  calorie  value  of  each  order  of  food.  Should  "  package  foods "  be 
similarly  graded? 

10.  Have  you  seen  in  your  postoffice  the  recent  Public  Health  Service 
poster  about  malaria  mosquitoes?  Is  that  a  legitimate  expenditure  of 
public  money? 

11.  Collect  all  the  health  superstitions  in  your  community,  such  as 
"  a  few  drops  of  lemon  juice  makes  any  water  safe  to  drink."  Show  why 
each  is  harmful,  and  present  convincing  arguments  to  confute  it. 

See  Beference  List  at  end  of  Appendix. 


CHAPTEK  XXVI 

HEALTH  ADMINISTRATION 

Although  the  ultimate  control  of  local  sanitary  conditions 
rests  with  the  several  States,  the  federal  government  has  charge  of 
various  important  public  health  relations.  How  wide  a  range  these 
cover  is  shown  by  Fig.  115. 

History  of  the  Federal  Service. — The  lower  right-hand  corner 
of  that  chart  gives  the  various  names  by  which  the  present  Public 
Health  Service  is  known.  It  really  dates  back  to  1798  when  Con- 
gress passed  an  act  for  the  relief  of  sick  and  disabled  seamen.  This 
small  beginning  accounts  for  the  present  location  of  the  bureau  in 
the  Treasury  Department,  the  customs  service  having  always  been 
closely  connected  with  the  medical  care  of  seamen. 

The  National  Board  of  Health  established  in  1879  for  four 
years  only  was  purely  advisory  and  one  of  its  chief  duties  was  to 
"report  to  Congress  ...  a  plan  for  a  national  public  health 
organization.^^  Since  the  bill  authorizing  it  did  not  carry  any  ap- 
propriation, it  dropped  out  of  service  and  the  national  health  func- 
tions reverted  to  the  earlier  Marine  Hospital  Service  mentioned  on 
the  chart. 

Powers  of  the  Public  Health  Service. — Quarantine  is  so  di- 
rectly one  of  the  marine  problems  that  control  of  quarantine  natu- 
rally became  part  of  the  work  of  this  growing  department.  By 
various  laws  enacted  by  Congress  the  powers  of  this  department 
have  come  to  include  not  only  port  quarantine  of  incoming  people, 
but  (1)  exclusion  powers  regarding  aliens;  (2)  quarantine  control 
of  incoming  goods  and  merchandise;  (3)  interstate  control  of  com- 
municable diseases;^  (4)  the  interstate  regulation  of  sera,  vac- 
cines, etc.;  (5)  the  sanitary  equipment  of  interstate  carriers  (trains, 
boats)  ;  (6)  the  control  of  malaria,  meningitis,  and  other  commu- 

^  The  Public  Health  Service  exercises  interstate  quarantine  over 
plague,  cholera,  typhoid  fever,  pulmonary  tuberculosis,  yellow  fever, 
smallpox,  leprosy,  typhus  fever,  scarlet  fever,  diphtheria,  measles,  whoop- 
ing cough,  infantile  paralysis,  meningitis,  and  Rocky  Mountain  spotted  or 
tick  fever. 

375 


376  HOME  AND  COMMUNITY  HYGIENE 

nicable  diseases  in  areas  adjoining  military  and  naval  reservations. 
The  Public  Health  Service  provides  medical  care  of  the  employees 
of  various  branches  of  the  government,  continuing,  of  course,  its 
original  charge  of  the  marine  service,  maintaining  (year  ending 
June,  1917)  19  marine  hospitals  and  119  relief  stations. 

Advisory  Relations. — The  advisor}^  character  of  this  federal 
department  is  also  very  important.  The  surgeon-general,  as  chief 
of  the  Public  Health  Service,  is  required  to  hold  each  year  at  least 
one  conference  with  the  State  health  authorities;  this  provides  op- 
portunity for  the  discussion  of  current  sanitary  problems,  and  helps 
toward  uniformity  in  public  health  legislation  and  administration. 
The  Public  Health  Service  also  frames  model  laws  and  codes  for 
the  various  States,  establishes  standard  registration  forms  (Figs. 
108  and  109),  conducts  local  investigations  of  epidemics  {e.g., 
smallpox)  or  sanitary  problems,  including  such  varied  questions  as 
pellagra,  rural  sanitation,  mental  hygiene,  industrial  wastes,  rat 
control  in  plague-infested  localities,  and  the  pollution  of  streams. 
The  annual  report  of  Surgeon-G-eneral  Blue  for  the  year  ending 
June,  1917,  is  a  most  interesting  and  enlightening  document  of 
nearly  four  hundred  pages,  and  many  more  details  can  be  gained 
from  even  a  casual  reading  of  this  report. 

Certain  other  powers  relating  to  public  health  are  vested  in  the 
Department  of  Agriculture ;  these  have  been  mentioned  under  adul- 
teration of  foods  and  meat  inspection,  which  also  covers  quar- 
antine for  foot-and-mouth  disease.  At  present  still  further  federal 
control  of  public  health  is  contemplated ;  this  includes  supervision 
of  the  State  health  departments  and  the  establishment  of  mini- 
mum requirements  and  standards  below  which  no  State  will  be 
allowed  to  fall. 

State  Health  Departments, — The  State  departments  vary 
greatly,  as  one  might  expect  in  a  country  like  the  United  States, 
where  State  constitutions  and  legal  standards  vary  so  greatly. 
That  but  twenty-six  States  are  included  as  wholes  in  the  "  registra- 
tion area"  (G)  tells  the  tale.  How  far  the  States  often  fall  below 
the  city  standards  is  shown  by  the  fact  that  the  registration  area  in- 
cludes cities  in  thirteen  States  not  included  in  the  twenty-six  above. 

Winslow  estimates  that  an  efficient  State  department  can  be 
run  for  five  to  ten  cents  per  capita.  The  State  department  should 
be   the    department   of   final    appeal    concerning   food    (including 


Orbanizatidn  Chart  U-5  Public  Health  Service 


Secretary  or   the  Treasury 
Assistant  Secretary 

op    THE 

Treasury 


US.Pobllc  Heallh>11uiiieIfefl61Sa*c, 
frem(?02lol9l2. 


I 


Fia.  115,— Chart  issued  by  tho  Public  Health  Service,  showing  the  many  phases  of  the  work  of  this  one  department. 


HEALTH  ADMINISTRATION  377 

milk),  water,  sewage,  and  epidemics.  Private  influence  often  pre- 
vents the  local  health  board  from  condemning  a  milk  supply,  en- 
forcing the  repair  of  leaky  sewers,  and  enforcing  the  registration 
and  quarantine  of  communicable  diseases.  A  case  in  point  is  the 
smallpox  epidemic  that  raged  unchecked  in  Niagara  Falls  until  the 
State  department  intervened.  Diagnostic  work  (tests  for  typhoid, 
identification  of  carriers,  and  examination  of  dogs  for  rabies)  is 
legitimate  State  work,  for  it  is  to  the  interest  of  the  State  to  con- 
trol such  diseases  in  all  communities  too  small  or  too  poor  to  do 
this  work  for  themselves.  In  large  States  enough  substations  for 
such  diagnostic  work  should  be  established  to  enable  reports  on 
samples  or  specimens  to  be  obtained  within  twenty-four  hours.  If 
established  in  connection  with  hospitals,  colleges,  and  medical 
schools,  a  sufficient  number  might  easily  be  secured  at  a  minimum 
cost  and  with  profit  to  the  institutions  themselves. 

State  departments  should  also,  by  health  education  or  publicity 
work,  uphold  the  local  departments,  and  increase  their  efficiency 
by  increasing  a  local  sense  of  pride  and  responsibility.  They  should 
also  establish  minimum  standards  below  which  no  community  can 
fall — whether  it  be  with  regard  to  the  infant  mortality  rate,  the 
percentage  of  industrial  diseases,  the  imperfect  birth  registrations, 
or  adulterated  drugs  and  foods.^  These  are  best  indicated  by  a 
sanitary  code  or  set  of  regulations  which  should  be  distributed 
widely,  so  that  local  communities  can  realize  when  they  can  seek 
protection  or  support  through  the  State  health  department.  For 
example,  communities  have  suffered  for  years  the  annoying  and 
dangerous  results  of  broken  sewers  or  sewers  that  empty  into  ad- 
joining waters  above  low-tide  levels,  not  knowing  that  the  State 
could  and  would  protect  them. 

State  departments  should  include  in  their  codes  all  the  regula- 
tions enforced  by  the  federal  government  regarding  interstate  com- 
munication. Meat  killed  in  Few  York  State,  but  not  fit  to  be 
shipped  across  the  State  line  to  Massachusetts  or  New  Jersey,  should 
not  be  sold  in  ISTew  York  State,  either.  It  is  a  sad  commentary  on 
our  State  laws  to  be  told  that  many  people,  perhaps  in  your  own 

'  Some  States  have  separate  Pure  Food  Commissions  not  part  of  the 
health  department.  This  paragraph  is  not  an  argument  for  changing  such 
organization  (though  centralization  is  usually  desirable),  but  rather  for  the 
establishment  and  enforcement  of  good  standards. 


378  HOME  AND  COMMUNITY  HYGIENE 

State,  insist  on  western  meat,  thus  securing  through  the  United 
States  interstate  regulations  safe  meat  wliich  they  cannot  trust 
their  own  State  to  provide  them.  Alcoholic  candies,  adulterated 
drugs,  and  injurious  foods  may  be  sold  in  quantities  in  your  State  by 
n^ufacturers  who  find  it  more  profitable  to  cater  thus  dishonestly 
to  a  small  market  than  to  supply  clean,  safe,  or  correctly  labelled 
commodities  for  interstate  trade. 

Local  Health  Departments. — The  local  health  department  is, 
of  course,  our  main  interest.  Often  a  local  health  department  can 
exercise  wider  powers  than  the  State,  particularly  if  local  public 
sentiment  is  with  it.  The  State  department  can  be  more  effective 
in  an  impartial  enforcement  of  existing  regulations,  but  the  local 
departments  are  much  more  elastic,  and  can  modify  their  powers 
almost  at  will.  Its  functions  and  organization  should  be- somewhat 
along  the  line  indicated  by  the  accompanying  diagram,  modelled 
after  that  recommended  by  Winslow.  This  includes  an  advisory 
body  or  "  board  of  health "  working  with  an  executive  termed  a 
health  officer.  In  large  communities  his  work  must  be  distributed 
among  several  health  departments,  as  indicated  in  the  diagram 
(Fig.  116). 

The  board  of  health  is  primarily  concerned  in  an  adequate  sani- 
tary code.  This  should  be  as  brief  as  possible  and  leave  out  all 
regulations  not  applicable  to  the  community  {e.g.,  industrial  re- 
strictions in  communities  not  containing  any  factories,  foundries, 
etc. ) . 

The  executive  power  should  be  vested  in  one  person,  a  health 
officer,  who  is  also  chairman  or  president  of  the  health  board.  The 
board  may  consist  of  representative  and  interested  business  men,  or 
preferably,  in  small  or  rural  communities,  of  the  school  inspector 
or  nurse,  a  physician  of  good  standing,  the  county  or  other  local 
registrar  or  official  interested  in  permanent  and  correct  records,  and 
the  health  officer.  In  all  cases  executive  action  should  be  vested  in 
one  man  who  can  give  sufficient  time  to  the  work.  It  often  occurs 
that  the  health  officers  (or  board  members)  are  employed  in  neigh- 
boring cities  and  are  not  easily  reached  by  the  people  they  would 
serve,  being  absent  all  day,  and  loth  to  have  their  home  or  personal 
plans  upset  by  irregular  outside  calls.  The  usual  monthly  meet- 
ings do  not  offer  adequate  opportunity  for  the  needs  of  the  people, 
especially  in  the  problems  of  communicable  diseases.     Every  com- 


HEALTH  ADMINISTRATION 


379 


mimity  should  itself,  or  in  conjunction  with  the  neighboring  town- 
ships, support  a  department  of  health  in  which  a  health  officer  can 
be  recompensed  for  the  time  given  to  the  community.  Often  mem- 
bers serve  without  any  compensation  and  cannot,  therefore,  always 
put  the  public  first. 

If  the  State  will  provide  adequate  diagnosis  facilities  at  con- 
venient centers,  even  rural  communities  could  afford  a  part-time 
health  officer  for  the  other  needs  of  the  community.  Samples  and 
specimens  sent  for  diagnosis  could  be  paid  for  directly  on  a  cost 
basis,  or  indirectly  in  the  State  taxes.  Local  health  organizations 
cost,  according  to  the  Eussell  Sage  Foundation,  anywhere  from 


of    H&alth 


Health 
Officer 

banltatioT) 

Food- 
Supplies 

Laboratotiu 

Coyntn  uTiicab/e 
Diseases 

Vital 
Statistics 

Tuherculosis 

Child 

Hygiene 

PubticL-tY 
Education 

Fig.   116. — Diagram  of  the  various  subdivisions  recommended  for  local  health  departments. 
(After  Winslow:    Healthy  Living.) 


three-fourths  of  a  cent  per  capita  (Clinton,  Iowa)  to  ninety-eight 
cents  (Seattle).  New  York  City  spends  fifty-eight  cents  per  capita 
and  has  probably  the  most  efficient  health  department  in  the  United 
States.  The  average  cost  is  thirty-two  cents,  but  the  rate  varies  in- 
versely with  the  population.  For  a  small  town  or  country  district 
with  a  population  of  4000  the  average  rate,  thirty-two  cents,  would 
give  us  but  $1280,  which  could  not  possibly  secure  a  well-trained 
health  officer  and  also  a  school  nurse  or  medical  inspector.  The  Mas- 
sachusetts scheme  of  co-operation  among  a  few  experts  who  make 
contracts  with  a  number  of  small  towns  is  worth  considering,  though 


380  HOME  AND  COMMUNITY  HYGIENE 

enough  should  be  raised  by  the  community  for  a  reliable  health  of- 
ficer r-esponsible  to  the  community.  Often,  the  wide  area  covered 
daily  by  the  country  physician  makes  him  a  desirable  person  for 
this  work.  His  training  prepares  him  more  definitely  for  the  dif- 
ferent phases  of  this  work  than  does  the  training  of  most  people  in 
the  community.  A  small  salary  would  enable  him  to  add  this 
duty,  for  that  would  enable  him  to  secure  a  clerk  or  other  helper 
for  mechanical  phases  of  his  own  work  or  parts  of  the  health  office 
work  {e.g.,  filling  out  records,  mailing  samples  for  diagnosis,  fol- 
low-up work  regarding  quarantine,  compulsory  repairs  to  sewers, 
etc.).  In  small  localities  the  health  board  or  department  is  often 
lethargic  or  actually  incompetent.  Often  the  positions  are  accepted 
for  political  or  selfish  reasons.  Public  health  education  is  the  only 
agency  that  can  permanently  affect  the  personnel  of  our  local  health 
departments,  and  insure  its  people  adequate  and  disinterested  ser- 
vice (see  Chapter  XXV). 

PROBLEMS 

1.  Send  for  the  Interstate  Quarantine  Regulations  issued  by  Public 
Health  Service  in  1916.  Support  the  rulings  given  there  for  ice,  water,  rat- 
proof  warehouses,  restrictions  on  the  transportation  of  patients,  and  the 
shipment  of  animals. 

2.  Describe  the  organization  of  the  health  work  in  your  State. 


GLOSSARY 


Note. — These  definitions  are  not  meant  to  be  complete  technical  defini- 
tions, but  to  aid  a  beginner  in  reading  this  text.  (See  Preface  for  further 
explanation. ) 


Acne.  A  skin  disease  commonly 
affecting  the  sebaceous  glands  of 
the  face,  the  several  types  charac- 
terized by  dilated  blood-vessels, 
various  types  of  eruption,  etc. 

Aerate.  To  expose  to  the  action  of 
air;  to  force  air  through. 

Agar.  The  term  agar  is  used  both 
for  a  substance  expressed  from 
seaweed  and  for  a  combination  of 
that  substance  and  meat  broth 
which  makes  a  solid  medium  for 
cultivating  bacteria.  It  forms  a 
semi-transparent  substance  resem- 
bling gelatin  in  appearance  (see 
pp.    10   and   11). 

Agar  Plate.  A  glass  dish  (Fig.  8) 
containing  a  layer  or  agar  in  or  on 
which  bacteria  may  be  grown  ( see 
Figs.  67  and  75). 

Agglutinins.  Substances  accumu- 
lating in  the  blood  as  a  reaction 
to  bacterial  growth  or  action; 
these  substances  cause  the  bac- 
teria to  clump  together  or  agglu- 
tinate (Fig  61)  as  a  preparatory 
step  to  their  destruction  by  the 
white  corpuscles. 

Algae.  Plants  of  relatively  simple 
structure,  commonly  growing  in 
water.  Common  illustrations  are 
the  slimy  green  scum  on  ponds 
and  the  stringy  green  masses  on 
dock  piles,  etc.  Bacteria  are 
usually  classed  in  the  lowest  divi- 


sion of  the  algae,  though  bacteria 
do  not  possess  the  green  coloring 
matter  characteristic  ot  most  algae. 

Alkali.  A  compound  of  hydrogen 
and  oxygen  with  such  substances 
as  sodium  or  ammonium;  these 
compounds  are  very  soluble  in 
water  and  can  neutralize  acids. 
Lime  and  any  other  compound 
that  has  neutralizing  power  for 
acids  are  popularly  spoken  of  as 
alkalies. 

Alveolar.  The  ultimate  fine  sub- 
divisions of  the  lungs  are  tiny 
rounded  sacs  or  pouches  called 
alveoli.  The  air  held  in  these  sacs 
is  spoken  of  as  alveolar  air. 

Anaphylaxis.     See  p.  210. 

Antibodies.  Reacting  substances 
formed  by  the  body  and  accumu- 
lating in  the  blood  in  response  to 
bacterial  growth  or  action.  These 
include  antitoxins,  agglutinins,  op- 
sonins, and  lysins  as  discussed  in 
this  text. 

Antiseptic.  Against  or  preventing 
sepsis  (or  decay).  In  treating 
wounds  it  is  not  always  sufficient 
to  make  sure  that  the  dressings 
are  aseptic  (G).  The  wound  it- 
self may  have  in  it  injurious  bac- 
teria which  came  from  the  air,  the 
near-by  surface  of  the  body,  or 
which  got  in  at  the  time  of  injury. 
Sterile  or  aseptic  dressings  will 
381 


382 


GLOSSARY 


not  prevent  injurious  organisms 
irom  developing.  To  hinder  their 
development,  chemicals  are  some- 
times used  either  on  the  dressings 
jOr  applied  directly  to  the  wounds. 
Since  these  prevent  sepsis,  they 
are  called  antiseptics.  Care  must 
be  taken  that  antiseptics  are  not 
too  strong,  or  they  will  destroy 
the  body  cells,  or  at  least  irritate 
them  and  so  delay  healing. 

Antitoxins.  The  substances  or  an- 
tibodies formed  in  the  body  in 
response  to  the  irritating  or 
poisonous  toxins  of  such  bacteria 
as  diphtheria  and  lockjaw  are 
called  antitoxins.  These  anti- 
toxins neutralize  the  toxins,  but 
do  not  aid  the  white  corpuscles 
nor  themselves  destroy  the  bac- 
teria. We  are  most  familiar  with 
the  word  antitoxin  in  connection 
with  the  formation  of  such  sub- 
stances in  large  quantities  by  the 
horse,  which  enables  us  to  use  the 
blood  of  such  horses  to  protect 
human  beings   (pp.  198  and  199). 

Arthritis.  A  disease  of  the  joints 
with  symptoms  resembling  rheu- 
matism  or  gout. 

Aseptic.  Aseptic  means  without  de- 
cay or  sepsis  (see  septic).  Wounds 
should  be  kept  in  an  aseptic  con- 
dition and  substances  in  contact 
with  wounds  should  be  aseptic, 
that  is,  without  any  decaying  par- 
ticles or  any  organisms  that  could 
cause  sepsis.  All  sterile  sub- 
stances are  aseptic.  Dressings  and 
instruments  may  be  made  aseptic 
by  boiling,  by  subjecting  them  to 
hot  steam,  or  by  such  chemicals 
as    alcohol     and     chloroform.     If 


other  chemicals  which  do  not 
evaporate,  such  as  carbolic  acid 
or  corrosive  sublimate,  are  used 
for  dressings,  they  are  usually 
made  antiseptic  rather  than 
merely   aseptic    (see  antiseptic). 

Auto-intoxication.  The  digestion 
or  breaking  down  of  protein  foods 
includes  many  temporary  or  tran- 
sitional stages,  some  of  which  are 
poisonous.  Xervous  or  other  func- 
tional derangements  of  the  diges- 
tive processes  may  lead  to  the 
accumulation  and  absorption  of 
unusual  amounts  of  intermediate 
poisonous  stages;  this  self -poison- 
ing is  termed  auto-intoxication 
(see  food  poisoning  also). 

Autopsy.  An  examination  of  a 
dead  body  to  determine  the  cause 
of  death,  the  seat  of  the  disease, 
etc.;   a  post-mortem  examination. 

Bacillus  (plu.  Bacilli).  A  rod- 
shaped  bacterium;  usually  used 
for  the  forms  possessing  motility 
or  the  power  to  form  spores  (Figs. 
2  and  102). 

Bactericidal.  Able  to  kill  bacteria; 
carbolic  acid,  alcohol,  etc.,  are 
bactericidal  substances. 

Bacterin.  (See  vaccine.)  Bacterin 
is  sometimes  used  as  a  name  for 
killed  cultures  of  bacteria  which 
are  used  to  produce  immunity  to 
a  given  disease.  The  vaccine  used 
in  typhoid  prevention  is  techni- 
cally a  bacterin. 

Blood  Covmt.  A  count  of  the  total 
number  and  proportion  of  white 
and  red  corpuscles.  This  count  is 
made  by  putting  a  carefully  meas- 
ured amount  of  accurately  diluted 
blood    on    a    special    slide,    which 


GLOSSARY 


383 


holds  a  given  amount  of  blood  over 
an  area  marked  off  in  tiny  squares 
to  facilitate  counting.     The  count 
is    made    through    a    microscope 
(Fig.l). 
Botulism.     Food  poisoning   due  to 
the  formation  of  toxin  by  B.  totu- 
linus,  usually  in  meats  which  have 
been   incompletely  cooked  or  pre- 
served,  or  which   have   stood   too 
long  since  cooked.     (See  p.  44.) 
Calorie.     A  unit  for  measuring  heat, 
used  commonly  to  express  the  fuel 
value  of  foods.     A  calorie  as  used 
in  that  connection  is  the  amount 
of   heat   necessary   to   raise    1000 
grams  of  water  1°  Centigrade. 
Calorimeter.  ( 1 )  Bomb  calorimeter : 
an  apparatus,  with  a  carefully  con- 
structed or  insulated  chamber  to 
prevent    outside    conditions    from 
influencing  the   results,   in   which 
foods  for  fuels  can  be  tested  to  de- 
termine the  heat  or  energy  they 
represent.     ( 2 )   Respiration  calori- 
meter:   a   similar   chamber,   large 
enough   to   hold   an   animal   or   a 
person,  used  to  determine  the  heat 
or    energy    used    under    varying 
conditions. 
Carbohydrates.     A  general  term  for 
sugars  and  starches    (see  each  in 
Glossary). 
Carbon    Monoxide.     Carbon    mon- 
oxide (CO)  is  a  very  injurious  gas 
which,    being    odorless,    often    ac- 
cumulates in  fatal  amounts  before 
the  danger  is  realized  (see  p.  132) . 
Carrier.      (See  p.  176.) 
Centigrade.     The   Centigrade   ther- 
mometer has  but  one  hundred  di- 
visions or  grades   (therefore,  liter- 
ally centigrade)   between  freezing 
and  boiling.     The  thermometer  in 


the  Appendix  gives  the  correspond- 
ing Centigrade  and  Fahrenheit 
temperatures  with  rules  for  trans- 
lating one  scale  into  the  other. 
Centrifuge.  The  principal  part  of 
a  centrifuge  is  a  horizontal  disk 
or  wheel  which  can  be  revolved 
very  rapidly — by  hand  power  or 
machinery.  In  this  disk  are  little 
cavities  in  which  tubes  or  flasks 
of  liquids  [e.g.,  whole  blood,  bac- 
terial cultures)  may  be  suspended. 
As  the  speed  of  the  disk  increases, 
these  tubes  tend  to  take  a  posi- 
tion approaching  the  horizontal, 
and  the  heavier  substances  in  these 
liquids,  e.g.,  bacteria,  blood  cor- 
puscles, or  dust  particles,  thrown 
outward  by  centrifugal  force,  set- 
tle in  the  ends  of  the  tubes.  The 
top  or  lighter  part  of  the  tube 
contents  can  then  be  poured  off, 
and  the  heavier  part  (bacteria, 
corpuscles)  obtained  relatively  free 
from  the  other  substances.  Liquids 
of  different  density  may  be  simi- 
larly separated  from  each  other  by 
centrifuging. 

C.C.    (See  cubic  centimeter.) 

Certified  Milk.      (See  p.  86.) 

Clinical.  This  term  refers  to  im- 
mediate or  direct  examination  of 
a  case;  it  commonly  includes  the 
symptoms  which  might  be  deter- 
mined by  observation  at  a  bedside 
or  in  a  hospital. 

CO.      (See  carbon  monoxide.) 

CO2.     Carbon  dioxide. 

Coccus   (plu.  Cocci).      (See  p.  3.) 

Colonies.      (See  p.  11.) 

Communicable.  Diseases  readily 
transferred  from  one  person  to  an- 
other are  now  spoken  of  as  com- 
municable.   This  term  is  supplant- 


384 


GLOSSARY 


ing  the  older  term  contagious  (see 
p.  172). 

Contagious.      (See  p.  172.) 

Cubic  Centimeter  (c.c).  A  small 
unit  of  size  used  in  the  metric  sys- 
tem, now  so  commonly  used  in 
scientific  measurements  and  de- 
scriptions. A  cubic  centimeter  of 
water  weighs  1  gram;  it  can  be 
visualized  better  by  remembering 
that  a  cubic  centimeter  of  such 
liquids  as  water  contains  about  16 
drops.  The  word  mil  is  sometimes 
used  for  one  cubic  centimeter,  as 
it  is  one  thousandth  of  a  liter,  the 
larger  liquid  unit  (a  little  over 
1  quart ) . 

Diagnosis.  A  careful  study  of  ex- 
isting conditions  and  a  conclusion 
based  upon  the  characteristic  signs 
or  symptoms  thus  observed.  A 
diagnosis  is  commonly  based  upon 
clinical  (G)  symptoms  only;  at 
present  an  examination  of  bac- 
teriological or  pathological  ma- 
terial is  often  made  to  confirm  the 
clinical  diagnosis,  e.g.,  typhoid. 

Dialysis.  The  passing  of  soluble 
substances  through  membranes : 
plant  or  animal  cell  membranes, 
or  artificial  membranes,  such  as 
dialyzing  bags   ( see  osmosis ) . 

Diastase.  An  enzyme  which  changes 
starch  to  sugar  or  sugar  to  starch. 

Dietary.  A  diet  system,  e.g.,  a  hos- 
pital dietary. 

Disinfect.  To  render  free  from  in- 
fectious or  disease-producing  or- 
ganisms; this  does  not  mean  that 
no  micro-organisms  are  left,  but 
that  there  are  none  which  can 
cause  disease.  Usually,  however, 
there  are  few  or  none  in  disinfected 


materials  or  substances.  ( See  ster- 
ilize, which  is  a  stronger  term.) 
Distilled.  Water  is  distilled  by 
first  boiling  it  and  then  collecting 
and  cooling  the  steam  or  vapor, 
thus  condensing  it  back  to  water. 
This  distilled  water  does  not  con- 
tain the  minerals  and  organic  ma- 
terials present  in  the  original 
water.  If  collected  and  cooled  in 
sterile  vessels,  it  may  be  sterile 
water  as  well,  though  distilled 
water  is  not  necessarily  sterile 
water,  as  spores  are  sometimes 
carried  over  in  the  steam,  espe- 
cially from  rapidly  boiling  water. 

Eflfluent.  That  which  flows  forth 
or  out,  e.g.,  the  water  flowing  out 
from  the  bottom  of  a  filter. 

Endemic.  Applied  to  any  disease 
produced  and  propagated  by  local 
conditions ;  e.g.,  malaria  and  hook- 
worm are  endemic  in  certain  areas 
of  the  United  States. 

Enzymes.  Substances  produced  by 
living  cells  which  bring  about  defi- 
nite changes  in  those  cells,  their 
food  materials,  or  their  stored 
substances,    e.g.,   diastase. 

Ether.  A  supposed  medium  which 
fills  all  space  and  through  which 
all  energy,  including  light,  is 
thought  to  be  transferred  by  wave- 
like motion. 

Eustachian  Tube.  A  tube  connect- 
ing the  cavity  between  the  nose 
and  throat  with  the  ear.  Infec- 
tion from  the  mouth,  etc.,  very 
easily  spreads  into  this  tube  and  so 
into  the  ear,  often  penetrating  the 
spongy  (mastoid)  bone  near  the 
ear  (mastoid  abscess) . 


GLOSSARY 


385 


Fats.  Such  foods  as  lard,  butter,  salt 
pork,  peanut  butter,  bacon,  cream, 
oleomargarine,  olive  oil,  are 
classed  as  fats. 

Feeces.  The  discharges  from  the  in- 
testines or  bowels. 

Fluorides.  Salts,  such  as  sodium 
fluoride. 

Fomites.  Substances  capable  of  ab- 
sorbing, holding,  and  transport- 
ing infectious  micro-organisms; 
mucus,  clothing,  etc.,  come  under 
this  headiug. 

Food  Poisoning.  This  is  a  gen- 
eral term  applied  to  all  stomach 
or  intestinal  disturbances  due  to 
foods.  It  covers  conditions  caused 
by  foods  naturally  poisonous  ( e.g., 
certain  mushrooms),  by  intro- 
duced, chemicals  [e.g.,  preserva- 
tives ) ,  by  toxins  found  in  the  food 
before  it  is  eaten  (as  in  botulism) , 
or  more  rarely  still,  by  ptomaines ; 
the  most  common  cause  of  food 
poisoning  is  due  to  the  activity 
of  organisms  afte.-  they  are  swal- 
lowed with  the  food.   (See  p.  44.) 

Food  Sensitives..    (See  p.  210.) 

Germicidal.  Used  for  substances  or 
agents  that  can  kill  germs  or 
micro-organisms.  Acids,  high  tem- 
peratures, etc.,  have  germicidal 
power.  Germicidal  substances  are 
also  called  disinfectants. 

Glycogen.  A  starchy  substance 
commonly  called  "  animal  starch," 
which  is  formed  in  the  liver.  Aa 
needed,  it  is  changed  back  to  sugar 
and  distributed  by  the  blood. 

Gonorrhoea.  A  dangerous  disease 
affecting  such  delicate  membranes 
as  the  eyes  and  the  genital 
area.     It  is  sometimes  transferred 


through  soiled  towels,  bedding  and 
personal  articles,  as  well  as  by 
personal  contact. 

Gram.  A  unit  of  weight.  One 
cubic  centimeter  of  pure  water  at 
its  greatest  density  (4°  C,  or  39° 
F. )  weighs  one  gram.  Gram  and 
cubic  centimeter  are,  therefore, 
practically  interchangeable  for 
water,  but  not  for  very  light, 
hea^y,  or  dry  substances. 

Ground  Water.  The  water  which 
is  found  in  the  depths  of  all  soils, 
and  which  has  an  irregular  in- 
definite upper  boundary  known  as 
the  water  table.  Capillary  water 
is  the  term  applied  to  the  water 
above  the  ground  water  or  water 
table. 

Haemoglobin.  The  compound  re- 
sponsible for  the  coloring  matter 
of  red  corpuscles  and  important 
as  a  carrier  of  oxygen.  Color  tests 
to  determine  the  per  cent,  of 
hsemoglobin  are  often  important 
in  diagnosis. 

Hookworm.  Small  round  worms 
(Necator)  which  cause  hookworm 
disease  (see  p.  176). 

Host.  An  organism  that  harbors 
another  as  a  parasite.  In  typhoid 
or  hookworm  man  acts  as  host 
for  the  typhoid  or  hookworm 
organisms. 

Hydrolyzed.  Hydrolysis  is  a  chem- 
ical change  attended  by  or  de- 
pendent upon  the  presence  of 
water.  Many  enzyme  changes  are 
of  this  kind;  for  example,  when 
starch  is  changed  to  sugar  the 
addition  of  water  is  the  first  step. 

Immunity.  This  is  defined  as 
freedom  or   exemption   from;    the 


386 


GLOSSARY 


literal  meaniBg,  "  not  in  service 
to,"  carries  the  same  implication. 
Incubation.  When  bacteria  are 
kept  at  temperatures  favorable  for 
growth  or  multiplication,  they  are 
said  to  be  incubated.  We  also 
speak  of  the  time  period  when  bac- 
teria are  multiplying  in  the  body 
as  the  incubation  period;  this  ex- 
tends from  the  time  when  the  dis- 
ease organism  enters  the  body  to 
the  time  the  patient  "  comes 
down  "  with  the  disease. 
Inert.     Neutral;    devoid    of    active 

chemical  properties. 
Infection.  Disease  organisms  that 
multiply  in  the  body  cause  infec- 
tion. Infection  may  be  localized, 
as  in  a  boil,  or  general,  as  in  blood 
poisoning. 
Infectious.  Caused  by  disease-pro- 
ducing organisms,  or  capable  of 
producing  disease  through  the 
transfer  of  such  organisms. 
Inhibited.  Prevented  from  growing 
or  multiplying  in  number.  Chemi- 
cals which  sterilize  or  disinfect  in 
strong  solutions  may  only  inhibit 
bacterial  growth  or  action  when 
used  in  weaker  solutions. 
Inoculate.  To  introduce  directly 
into  the  body,  as  into  the  skin,  the 
abdominal  cavity,  or  a  blood- 
vessel; used  mainly  for  the  intro- 
duction of  micro-organisms ;  cura- 
tive substances  (serum,  etc.)  are 
more  commonly  spoken  of  as 
injected. 

Inorganic.  Not  now  or  never  hav- 
ing been  a  living  organism;  min- 
eral rather  than  organic  is 
an    easily    understood    difference. 


though  organic  substances  con- 
tain minerals   ( see  organic ) . 

Lactic.  Commonly  applied  to  milk 
changes,  such  as  lactic  fermenta- 
tion. The  lactic  acid  produced  in 
souring  milk  is  common  in  many 
other  substances  containing  sugar. 

Latrine.  A  privy,  especially  the 
trough  type  common  in  camps  or 
barracks. 

Lactose.     Milk  sugar. 

Larvae.  The  form  following  the 
egg  stage  in  such  insects  as  the 
fly,  butterfly,  etc.  It  is  usually  a 
maggot  or  a  worm-like  form. 

Leaching.  Separating  or  washing 
out  soluble  matter  by  draining  or 
percolating. 

Lesions.  Injuries,  diseased  areas, 
or  morbid  changes  in  organs  or 
tissues;  these  include  bruises, 
ulcers,  and  inflamed  as  well  as 
disintegrated  areas. 

Lymph-nodes.  Small  lymph- 
glands  or  collections  of  lymph  tis- 
sue. Certain  types  of  white  cor- 
puscles are  produced  in  these 
lymph-glands. 

Lysins.  Substances  (antibodies) 
formed  in  the  body  as  a  reaction 
to  bacteria  or  other  micto-organ- 
isms  (see  p.  194). 

Media.  Substances  used  for  the 
cultivation  or  growth  of  micro- 
organisms; milk,  beef  broth,  gela- 
tin are  common  media.  Special 
media  are  used  for  certain  organ- 
isms; these  may  contain  egg 
(tuberculosis),  serum  (diph- 
theria),   special    sugars,    etc. 

Medulla  Oblongata.  The  extension 
of  the  spinal  cord  just  within  the 


GLOSSARY 


387 


skull;  it  is  an  important  centre 
for  breathing,  swallowing,  etc. 

Metabolic.      (See  metabolism.) 

Metabolism.  A  comprehensive  term 
for  all  the  cell  changes,  including 
the  change  of  stable  non-living 
food  substances  to  complex  un- 
stable living  material  and  the 
breaking  down  of  that  living  ma- 
terial to  simpler  and  more  stable 
substances;  metabolism  includes 
all  the  upbuilding  and  energy- 
producing  changes  in  a  cell. 

Metric  System.  A  system  of 
weights  and  measures  commonly 
used  in  Europe,  and  now  generally 
adopted  in  this  country  for  scien- 
tific work.  It  is  much  simpler 
than  our  own  systems,  and  has 
small  units  more  suitable  for  fine 
measurements.  The  only  units 
used  in  this  text  are  the  cubic  cen- 
timeter and  the  gram,  which  are 
described  in  this  glossary.  The 
Centigrade  thermometer  is  based 
on  the  same  system  of  units,  vary- 
ing by  tens  or  hundreds. 

Micro-organism.  An  organism  of 
very  small  size,  making  a  micro- 
scope necessary  for  its  detailed 
study. 

Mil.     (See  cubic  centimeter.) 

Motility.    The  power  of  locomotion. 

Mucus.  The  viscid  secretion  of 
certain  membranes;  we  are  most 
familiar  with  it  as  the  excessive 
secretion  of  such  membranes  as 
the  nose  and  throat  attending  colds. 

Nephritis.  An  inflammatory  dis- 
ease of  the  kidneys  affecting  the 
secretory  tubules. 

Non-pathogenic.  Not  capable  of 
causing  or  producing  disease. 

25 


Opsonins.  Antibodies  produced  as 
a  reaction  to  invading  organisms 
which  aid  the  white  corpuscles  in 
digesting  and  destroying  them  ( see 
p.  196). 

Optimum.  Used  to  designate  the 
condition  or  conditions  producing 
the  best  results. 

Organic.  All  organic  substances 
contain  carbon  as  an  essential  ele- 
ment; usually  applied  to  sub- 
stances which  are  or  have  been 
part  of  living  organisms;  flour, 
milk,  and  spores  are  organic  sub- 
stances in  contrast  to  iron  rust, 
table  salt,  and  air,  which  are  inor- 
ganic  (see  inorganic). 

Osmosis.  The  term  osmosis  is  now 
often  limited  to  the  passage  of 
water  through  membranes,  dialysis 
being  used  for  the  passage  of 
substances  in  solution  such  as 
sugars,  salts,  and  acids.  There  is 
a  constant  exchange  of  substances 
in  and  out  of  cells  by  these  two 
processes. 

Oxidation.  The  union  or  combina- 
tion of  oxygen  with  other  sub- 
stances. Oxidation  breaks  down 
or  decomposes  many  complex  sub- 
stances; this  change  in  structure 
from  the  complex  to  simpler  forms 
liberates  energy.  Much  of  our 
energy  (and  heat)  is  obtained 
by  oxidizing  food  substances, 
hence  the  need  for  a  rich  blood 
supply  of  oxygen.  Foods  are 
sometimes  split  into  simpler  sub- 
stances without  oxygen  entering 
into  the  change;  oxidation  is 
usually,  however,  the  more  eco- 
nomical way  of  producing  cell 
energy. 


388 


GLOSSARY 


Parasite.     An  organism  which  lives 

upon     anotlier     living     organism. 

Tapeworms,    bacteria,    and    molds 

which  cause  ringworm  are  exam- 

.  pies  of  human  parasites. 

Paratyphoid.  An  intestinal  dis- 
ease, or  the  organism  producing 
it;  it  resembles  tphoid,  therefore 
the  prefix,  para  ( see  p.  44 ) . 

Paresis.  A  partial  or  a  general, 
progressive  paralysis ;  advanced 
st-ages  cause  one  type  of  "  soften- 
ing of  the  brain." 

Pasteurization.  As  applied  to 
m.ilk,  pasteurization  means  heat- 
ing the  milk  to  a  temperature 
which  insures  the  killing  of  all 
pathogenic  organisms  which  might 
occur  in  milk.  For  the  changes 
attending  such  heating  of  milk 
see  Fig.  28  and  p.  82. 

Pathogenic.  Capable  of  causing  or 
producing  disease. 

Pathogens.  Used  to  designate 
micro-organisms  which  are  capable 
of  causing  or  producing  disease. 

Pellagra.  A  deficiency  or  nutri- 
tional disease  with  various  clinical 
manifestations:  intestinal  disturb- 
ances, skin  eruptions  or  "  burns," 
and  nervous  derangements,  such  as 
melancholia  and  mania. 

Peristaltic.  A  term  referring  to  the 
rhythmical  movement  of  the  small 
intestine. 

Petri  Dish.  A  double  glass  dish  or 
plate  used  to  cultivate  micro- 
organisms (Fig.  8).  (See  also 
agar  plate.) 

Phagocyte.    (See  white  corpuscles. ) 

Phthisis.  Tuberculosis,  especially 
the  pulmonary  (or  lung)   type. 


Plasmolysis.  A  shrinkage  or  col- 
lapse of  the  cell  attendant  upon 
the  loss  of  water.  The  "  keeping 
power  "  of  brines  and  strong  sugar 
solutions  is  due  to  their  power  to 
abstract  water  from  micro-organ- 
isms, and  so  prevent  them  from 
growing. 

Plate  Coiuits.  Plate  counts  are 
made  to  determine  the  nrunber  of 
bacteria  in  a  given  amount  of  milk, 
water,  etc.  (See  plate  count  in 
Appendix. ) 

Poliomyelitis.     Infantile  paralysis 

Polluted.  Containing  organic  ma- 
terial, the  products  of  plant  or 
animal  decay    (see  p.  93). 

Potable.    Fit  or  safe  to  drink. 

Precipitate.  To  cause  to  fall  or  set- 
tle more  rapidly  than  would  other- 
wise occur. 

Precipitins.  Substances  found  in 
the  blood  as  a  reaction  to  foreign 
bodies  in  the  blood  stream,  such 
as  bacteria  and  the  blood-cells  of 
another  animal    (see  p.   194). 

Presumptive  Tests.  Because  of  the 
difficulty  in  identifying  bacteria 
by  their  shape  and  size,  we  de- 
pend partly  on  their  products  or 
results  when  grown  in  certain  food 
materials.  For  example.  Bacillus 
coli  can  use  lactose,  forming  acid 
and  gas  with  a  definite  proportion 
of  hydrogen  and  carbon  dioxide.  If 
water  or  milk  containing  this  same 
organism  is  added  to  lactose  broth, 
we  get  much  the  same  results. 
Knowing  this,  we  use  lactose  as  a 
test  substance,  and  use  it  for  test- 
ing water,  milk,  etc.  If  the  re- 
sults are  like  those  obtained  from 


GLOSSARY 


389 


B.  coli  growths,  we  conclude  or 
presume  that  B.  coli  is  present. 
Such  tests  are  called  presumptive 
tests  (see  p.  98). 

Protein.  The  most  important  or 
foundation  substance  of  all  cells 
or  organisms,  as  indicated  by  the 
literal  meaning  of  the  word,  first 
in.  White  of  egg  is  a  good  com- 
mon example  of  proteins.  Pro- 
teins— more  or  less  mixed  with 
other  foods  such  as  starches — are 
derived  from  such  foods  as  beans, 
peas,  skim-milk,  American  cheese, 
lean  meats,  and  eggs. 

Protozoa.  The  lowest  group  of  ani- 
mals, simple  one-celled  forms  (see 
Figs.  46,  4  and  3). 

Ptomaines.  These  are  alkaloid-like 
substances,  formed  in  the  decom- 
position of  proteins  (amino-acids) . 
Some  of  them  are  poisonous, 
though  most  are  not  (see  food 
poisoning). 

Pulmonary.  Relating  to  the  lungs, 
as  pulmonary  tuberculosis. 

Putrefaction.  Decay  or  decomposi- 
tion, especially  the  types  accom- 
panied by  the  formation  of  objec- 
tionable odors ;  these  are  very 
commonly  due  to  organisms  which 
do  not  get  their  energy  by  oxi- 
dation. 

Registration  Area.  That  part  of 
the  United  States  in  which  the 
death  record  part  of  the  vital  sta- 
tistics is  thought  to  be  at  least  90 
per  cent,  correct.  It  now  includes 
26  States  and  certain  cities  in  13 
other  States. 

Respiration.  Respiration  is  essen- 
tially a  cell  process,  another  name 
for  tlie  oxidation  processes  of  the 


living  body.  Breathing  is  an  ac- 
cessory to  respiration,  but  is  not 
respiration  itself — as  now  gener- 
ally used  in  this  chemical  sense. 

Rickets.  A  nutritional  disease  of 
children,  characterized  by  malfor- 
mation of  the  skeleton  and  lack  of 
muscular  control,  or  co-ordination. 

Saprophyte.  An  organism  which 
lives  on  organic  material,  but  not 
on  a  living  host.  Bacteria  or 
molds  living  on  bread,  dead  fish, 
milk,  are  all  saprophytes.  Most 
bacteria  are  saprophytes. 

Saturated  (Saturation).  When  a 
liquid  has  dissolved  or  absorbed 
all  it  can  of  a  given  substance,  it 
isi  said  to  be  saturated,  or  to  make 
a  saturated  solution.  Air  may  be 
similarly  spoken  of  as  saturated 
with  water. 

Scurvy.  Authorities  differ  as  to 
the  relative  causal  importance  of 
diet  and  micro-organisms  in  this 
disease,  which  is  characterized  by 
anaemia,  debility,  bleeding  gums, 
and  scab-like  manifestations  on 
the  skin. 

Sepsis.     See  septic. 

Septic.  Undergoing  or  showing 
signs  of  decay.  A  septic  tank  is 
one  where  sewage  is  held  until  it 
decays  or  decomposes  past  the 
ordinary  malodorous  stages.  A 
septic  wound  has  decay-producing 
organisms  growing  in  it;  pus, 
"  proud  flesh  "  are  indications  of 
such  septic  conditions. 

Serum  (Sera).  The  liquid  of  the 
blood  (plasma)  lacking  not  only 
the  red  and  white  corpuscles  but 
the  fibrin  of  the  plasma  as  well. 
(See  whole  blood.) 


390 


GLOSSARY 


Siphon.  To  discharge  over  or 
through  a  bend  in  a  pipe  or  tube. 
The  S-curve  in  a  trap  makes  a 
siphon  (Fig.  68).  The  water 
pressing  down  toward  the  trap  has 
sufficient  force  to  carry  the  water 
up  over  the  curve  or  bend,  making 
a  continuous  stream  of  water  or 
siphon.  TQiough  less  evident  at 
first,  the  siphon  action  can  be  seen 
in  water  closets  (Fig.  73)  as  well 
as  in  simple  S-traps. 

Sludge.  The  semi-solid  part  of 
sewage  left  after  crude  sewage  has 
been  filtered,  or  acted  upon  by  bac- 
terial action.  ( See  septic  tank  and 
activated  sludge  tank  also.) 

Spirillum  (Spirilla).  One  of  the 
classes  of  spiral-shaped  bacteria  is 
called  Spirillum;  Vibrio  is  an- 
other class  of  very  short  spirals. 
(See  Spirochceta.) 

Spirochaeta.  The  protozoa  include 
a  group  of  spiral-shaped  organ- 
isms called  Spirochcetce.  Spiro- 
chsetae  cause  such  diseases  as  re- 
lapsing fever  and  syphilis. 

Spore.  A  stage  in  the  life  history 
or  development  of  some  bacteria. 
Spores  are  quite  resistant  to  most 
unfavorable  conditions,  and  are 
usually  formed  in  response  to  such 
environmental  influences. 

Sputum.  Mucus  accumulating  in  or 
ejected  from  the  mouth  or  throat. 

Stains.  Special  dyes  or  stains  are 
used  to  color  bacteria  so  they  may 
be  seen  more  definitely.  No  real 
progress  was  made  in  identifying 
bacteria  until  after  the  discovery 
of  aniline  dyes  by  Perk4n. 

Starches.  Foods  like  hominy,  corn- 
meal,    flour,    rice,    macaroni,    spa- 


ghetti, cornstarch,  bread,  beans, 
peas,  potatoes,  and  bananas  are 
rich  in  starch  and  spoken  of  as 
starchy  foods.  Peas,  beans,  whole 
wheat  flour  are  also  rich  in  pro- 
teins as  well. 

Sterile.    Free  from  micro-organisms. 

Sterilize.  To  free  from  all  micro- 
organisms by  such  agents  as  heat 
or  chemicals.  A  stronger  term 
than  disinfect,  which  has  as  its 
aim  killing  all  disease-producing 
organisms. 

Streptococci.  Coccus  or  globular 
organisms,  which  adhere  in  chains. 
A  rather  long-chained  type  is 
shown  in  Fig.  58. 

Sugars.  Fruits  such  as  dates  and 
raisins  are  rich  in  sugar;  more 
condensed  sugars  are  cane  sugar, 
beet  sugar,  candy,  molasses,  corn 
syrup  and  honey. 

Syphilis.  A  dangerous  disease 
sometimes  transferred  by  common 
drinking  glasses,  towels,  bedding, 
or  personal  articles,  as  well  as  by 
personal  contact. 

Tetanus.  Lockjaw  organisms  or 
the  disease  caused  by  them. 

Therapeutic.  Having  curative  or 
healing  properties. 

Trephining.  Removing  a  small 
disk  or  piece  of  the  skull  to  re- 
move presure  upon  the  underlying 
part  of  the  brain,  remove  injured 
tissue,  etc. 

Trichinella  (Trichina).  Round 
worms  (as  opposed  to  flat  worms 
like  tapeworms)  which  liv©  in 
pigs  as  well  as  man.  They  injure 
mainly  by  perforating  the  intes- 
tinal walls  and  invading  the 
muscles. 


GLOSSARY 


391 


Toxins.  Poisons  formed  by  bac- 
teria. These  toxins  may  be  ex- 
creted freely  and  accumulate  in 
the  blood,  irritating  the  body  cells 
generally,  as  in  diphtheria,  or  they 
may  affect  definite  tissues,  as  the 
nerve  tissue  in  lockjaw  (tetanus). 

Trypanosomes.  Protozoa  causing 
diseases  in  animals,  but  none  com- 
mon in  man  in  this  country 
(Fig.  3). 

Tuberculin.     (See  p.  216.) 

Vaccine.  Vaccine  is  a  term  used 
for  substances,  such  as  bacteria, 
which  are  inoculated  into  the  body 
to  protect  it  against  disease.  Vac- 
cines are  made  of  either  living  or 
dead  organisms;  e.g.,  living  in 
smallpoix  vaccine  and  dead  ones  in 
typhoid  vaccine.  If  living  organ- 
isms are  used,  they  are  first  weak- 
ened in  some  way  to  lessen  their 
effect   (see  pp.  203-205). 

Virulent.  Highly  pathogenic  or  ex- 
tremely toxic  or  poisonous. 

Virus.  A  term  for  unknown  causal 
agents  of  disease.  The  material 
used  to  vaccinate  against  smallpox 
is  commonly  spoken  of  as  small- 
pox virus.  Similarly  we  speak  of 
the  virus  of  hog-cholera,  and  of 
foot-and-mouth  disease.  When  the 
causal  organism  is  known,  it  is 
usually  spoken  of  by  its  group 
name  ( Streptococcus,  Trypano- 
some.  Spirillum,  etc.)  or  by  the 
general  names  bacteria  or  pro- 
tozoa. 

Vital  Resistance.  The  resistance 
of  living  organisms  against  such 
untoward  agents  as  bacteria  and 
fatigue.  Upon  the  individual  re- 
sistance  depends  the   individual's 


freedom  from  disease,  or  the  sever- 
ity of  the  attack.  This  resistance 
is  in  great  part  dependent  upon 
the  activity  of  the  white  corpus- 
cles, and  the  production  of  such 
antibodies  as  antitoxins  and 
opsonins. 

Vitamines.     (See  p.  27.) 

Water  Gas.  Illuminating  gas  made 
by  passing  steam  through  a  mix- 
ture of  hydrocarbons  (carbon  and 
hydrogen  compounds ) . 

White  Corpuscles.  The  blood  con- 
tains two  kinds  of  corpuscles,  red 
and  white.  The  white  corpuscles 
vary  more  than  the  red  in  size  and 
activity;  although  several  kinds 
are  found  in  all  human  blood,  they 
may  be  divided  into  two  main 
groups,  those  that  contain  but  one 
nucleus  and  those  that  contain 
several  nuclei.  White  corpuscles, 
though  relatively  few  in  number, 
are  most  important;  they  help  in 
blood  clotting,  in  keeping  a  pro- 
tein balance  in  the  blood,  etc. 
Those  possessing  several  nuclei 
have  another  important  function: 
they  surround  or  envelop  and 
finally  digest  bacteria,  thus  pro- 
tecting the  body  against  invading 
organisms.  Sometimes  dozens  of 
bacteria  may  be  seen  inside  one 
white  corpuscle  (Fig.  50;  see 
p.  195). 

Whole  Blood.  Literally  whole 
blood,  without  subtracting  the 
corpuscles.  Blood  less  corpuscles 
is  spoken  of  as  plasma;  if  the 
fibrin  is  also  taken  out,  it  is  called 
seriun;  in  clotted  blood  the  liquid 
serum  collects  at  the  sides  or  top 
of  the  jar  or  container. 


APPENDIX 

DISINFECTION 

In  this  appendix  are  treated  only  the  disinfectants  not  included  in 
the  table  on  p.  189  and  those  for  which  special  directions  are  necessary. 
The  present  high  price  of  carbolic  acid  and  related  substances  is  the  reason 
for  omitting  them.  In  this  connection,  reference  may  be  made  again  to 
the  commercial  high-coefficient  disinfectants  (p.  191),  calling  attention  to 
their  value  and  warning  patrons  to  purchase  only  those  with  a  definite 
statement  concerning  the  carbolic  acid  strength  or  coefficient. 

Bichloride  of  mercury  is  not  included,  partly  because  it  is  now  impos- 
sible to  buy  it  without  a  physician's  prescription  in  most  intelligent  com- 
munities, and  partly  because  carelessness  is  attended  with  so  many  serious 
results,  making  its  use  inadvisable  when  so  many  satisfactory  substitutes 
are  available. 

Formaldehyde  Disinfection, — Formaldehyde  or  formalin  is  usually 
purchased  in  40  per  cent,  solution.  Formaldehyde  is  not  a  good  insecticide; 
this  fact  leads  some  to  question  its  value  as  a  disinfectant,  but  formalde- 
hyde is  one  of  the  best  gas  disinfectants  known  for  rooms,  etc.,  as  it  injures 
but  few  substances.  Its  advantages  and  disadvantages  may  be  summed  up 
as  follows:  A  powerful  germicide,  little  affinity  for  other  organic  matter, 
not  poisonous,  and  not  injurious  to  delicate  fabrics,  paints,  metals  (except 
iron  on  prolonged  contact).  Disadvantages:  Not  reliable  when  the  tem- 
perature is  much  below  65°  F.,  irritating  to  the  eyes  and  nose,  and  requires 
a  long  period  of  exposure  and  considerable  preparatory  work  [e.g.,  sealing 
cracks ) . 

Liquid  Disinfectant. — For  a  liquid  house  disinfectant,  dilute  the  for- 
maldehyde as  purchased  (40  per  cent.)  by  adding  ten  times  as  much  water. 
This  mixture  will  disinfect  small  articles  immersed  in  it  in  ten  minutes. 
Excreta  covered  generously  with  this  mixture  (at  least  as  much  mixture 
as  excreta)  will  be  disinfected  in  two  to  three  hours.  Bedding,  etc.,  can 
be  satisfactorily  soaked  in  the  same  mixture;  this  may  be  desirable  if  the 
attendants  cannot  be  certain  that  soiled  articles  will  be  boiled  before 
handling.  Formaldehyde  is  irritating  to  the  hands  and  therefore  not 
popular  as  a  liquid  disinfectant. 

Room  Disinfection. — For  closets,  chests,  etc.,  the  formaldehyde  as 
purchased  (40  per  cent.)  can  be  used,  distributing  10  ounces  for  each  1000 
cubic  feet  to  be  disinfected.  All  cracks,  keyholes,  etc.,  should  be  sealed 
by  pasting  on  strips  of  paper  before  disinfection  is  begun.  After  spraying, 
close  the  compartment,  closet,  etc.,  for  at  least  eight  hours. 

For  rooms,  formaldehyde  can  be  used  as  above.     It  is  better,  however, 

393 


394  APPENDIX 

to  modify  the  method  to  make  sure  of  two  factors  that  increase  the  efficiency 
of  the  formaldehyde :  ( 1 )  Moisture,  which  increases  the  penetrating  power 
of  the  formaldehyde;  and  (2)  heat,  which  increases  its  chemical  action. 
This  is  usually  done  by  using  potassium  permanganate  with  the  formalin, 
but  as  it  is  often  impossible  to  get  potassium  permanganate  in  many  locali- 
ties, the  following  directions  are  given:  Secure  an  old  watertight  cooking 
utensil  which  you  can  afford  to  discard.  In  it  place  the  necessary  amount 
of  formaldehyde,  10  ounces  as  purchased  to  every  1000  cubic  feet,  adding 
about  the  same  amount  of  water.  When  ready  to  leave  the  room,  place 
it  over  a  flame  or  fire  (gas  burner,  oil  stove  or  lamp,  etc.)  and  leave  the 
room  promptly  because  of  the  effect  on  the  eye  and  nasal  membranes.  If 
convenient,  leave  the  room  closed  until  the  next  day;  on  re-entering,  open 
the  door  wide  for  a  short  time  and  then  open  the  nearest  window  quickly, 
retiring  until  the  irritating  effects  are  not  noticeable. 

Lime. — For  disinfection  do  not  use  air-slaked  lime,  but  "  quicklime." 
It  can  now  be  purchased  in  tin  cans  in  small  quantities.  Add  one  pint  of 
water  to  two  pounds  of  quicklime.  If  rapid  effervescence  and  crumbling 
or  dissolving  of  the  lime  does  not  occur,  the  lime  is  not  of  good  quality  and 
will  not  disinfect  as  rapidly  or  as  completely  in  the  proportions  advised.  To 
this  slaked  lime,  add  four  times  as  much  water,  mixing  thoroughly.  Keep 
it  in  airtight  containers  as  3.  stock  solution  for  use  as  needed.  This  stock 
solution  will  disinfect  excreta  in  two  hours;  it  may  be  used  in  outhouses, 
chicken  yards,  etc. 

Bleaching  Powder  or  Chlorinated  Lime. — Bleaching  powder  (see 
p.  108)  may  now  be  purchased  in  small  tin  containers  (5  cents  and  upward) . 
It  should  bear  a  label  stating  plainly  the  amount  of  available  chlorin. 
Commercial  forms  usually  contain  at  least  30  per  cent,  (though  the  United 
States  standard  demands  35  per  cent.).  For  use,  rub  the  contents  of  the 
can  up  in  a  little  water,  making  a  pasty  mass,  and  then  dilute  to  the  desired 
strength;  six  ounces  of  bleaching  powder  to  a  gallon  of  water  is  the 
general  stock  solution  for  30  per  cent,  bleaching  powder.  It  bleaches  tex- 
tiles and  corrodes  metals  and  its  odors  are  readily  absorbed  by  food,  so  its 
house  uses  are  somewhat  limited.  This  substance  has  an  affinity  for  organic 
matter,  and  should,  therefore,  be  used  generously  in  disinfecting  excreta, 
which  contains  much  organic  material  besides  the  bacteria  we  desire  to 
destroy.     Add  at  least  equal  parts  of  stock  solution  to  discharge. 

Bleaching  powder  is  sometimes  valuable  in  emergency  treatment  of 
water.  One  teaspoonful  of  bleaching  powder  (35  per  cent,  available  chlo- 
rine) is  added  to  a  pint  of  water  to  make  a  stock  solution.  The  clear  fluid 
of  the  stock  is  sufficiently  strong,  as  chlorine  is  very  soluble.  This  stock 
solution  may  be  used  as  follows:  one  teaspoonful  to  10  gallons,  36  drops 
to  a  gallon,  or  nine  drops  to  a  quart.  Let  the  solution  stand  at  least 
15  minutes,  preferably  25  minutes  (drinking  water,  washing  lettuce,  p.  235). 


APPENDIX  395 

The  administration  of  bleaching  powder  as  purchased  in  bulk  is  not 
a  simple  matter,  and  needs  to  be  carefully  controlled  to  insure  a  known 
strength.  For  swimming  pools  bleaching  powder  seems  the  best  disin- 
fectant. Those  responsible  for  the  care  of  such  pools  should  secure  the 
advice  of  the  State  department  of  health  concerning  reliable  firms  for 
purchasing  good  hypochlorites  and  details  of  mixing  and  administering. 

HOUSEHOLD   PESTS 

Flies.— House  control  can  be  secured  by  traps  (see  p.  279),  by  sticky 
fly-paper  {especially  the  strips,  which  do  not  demand  table  or  other  needed 
horizontal  surface  for  exposure),  and  by  fly-poisons.  Of  these  poisons, 
formalin  is  perhaps  the  most  satisfactory,  as  it  is  not  so  poisonous  to  man 
as  other  recommended  substances.  Add  four  ounces  of  formalin  to  a  quart 
of  milk,  or  a  quart  of  sugar  and  water,  and  moisten  crusts  of  bread  placed 
in  light  places. 

Electric  fans  at  doorways  will  keep  flies  from  entering,  as  they  dislike 
strong  winds.  Strong  odors,  such  as  decomposing  food,  will  attract  flies. 
Odors  pleasant  to  man  are  said  to  be  disagreeable  to  flies;  and  good  results 
are  attributed  to  lavender  water,  etc.,  Avhen  sprinkled  around  the  room. 
Water  is  necessary  for  life ;  perfectly  dry  sinks,  crumbless  tables,  etc.,  have 
a  slight  negative  effect,  therefore. 

Stable  refuse  is  the  favorite  breeding  place  of  most  flies,  and  proper  care 
of  manure  will  help  greatly — closed  pits,  etc.  Such  pits  are  not  always 
possible,  and  chemical  treatment  is  necessary.  Borax  (one  pound  to  12 
gallons  of  water)  will  treat  12  bushels  or  16  cubic  feet  of  manure,  destroy- 
ing 90  per  cent,  of  all  maggots.  If  not  more  than  15  tons  of  such  treated 
manure  is  added  per  acre,  the  crops  do  not  seem  to  be  injured.  Hellebore  is 
also  effective  in  the  proportion  of  one-half  pound  to  10  gallons  of  water  used 
for  every  eight  bushels  or  ten  and  two-thirds  cubic  feet. 

Other  Household  Pests. — Ants,  cockroaches,  and  bedbugs  may  have 
hygienic  problems  connected  with  their  activities.  Ants  may  be  eliminated 
by  spreading  near  their  haunts  equal  parts  of  powdered  sugar  and  tartar 
emetic.     This  causes  such  violent  purging  that  death  ensues. 

Cockroaches,  croton  bugs,  can  usually  be  controlled  by  generous  dis- 
tribution of  sodium  fluoride,  mixed  with  equal  parts  of  flour,  talc,  etc. 
Sodium  fluoride  is  the  basis  of  most  roach  powders. 

Bedbugs  are  not  so  readily  affected  by  formaldehyde  as  by  sulphur. 
Painting  beds,  woodwork,  cracks,  etc.,  and  repapering  are  usually  very  help- 
ful measures.  Kerosene  is  a  good  substance  for  painting  cracks,  bedsteads, 
springs,  etc.  Corrosive  sublimate  (saturate  solution)  is  most  efficient,  but 
because  of  its  very  poisonous  character  it  cannot  be  purchased  in  many 
localities.  It  discolors  plaster,  but  can  safely  be  applied  with  a  brush  on 
most  other  surfaces. 


396  APPENDIX 

Rats  and  mice  should  be  exterminated.  Rat-proof  walls,  floors,  and 
foundations  should  be  used  everywhere,  and  when  necessary  these  should 
be  supplemented  by  some  of  the  various  good  traps  now  on  the  market. 

PASTEURIZATION  OF  MILK 

'  Pasteurization  of  Milk. — Some  milk  stations  and  city  baby-welfare 
stations  sell  at  cost  price  a  pasteurizer  for  home  use.  They  may  also  be 
purchased  in  many  department  stores,  at  atout  $1.25  to  $1.75  each.  For 
other  homes  the  following  directions  may  be  helpful,  as  they  do  not  demand 
a  thermometer.  Thermometers  are  expensive  and  easily  broken.  ( 1 )  Fill 
each  of  six  milk  bottles  to  the  level  demanded  by  the  age  or  the  size  of  the 
child.  ( 2 )  Tie  on  each  bottle  a  cap  of  clean  paper  to  prevent  a  milk  film 
from  forming:  this  also  keeps  flies  away  from  the  milk  while  cooling,  etc. 
(3)  Place  the  bottles  in  a  wire  basket  or  frame  (vegetable  frame)  in  a  large 
cooking  utensil  (six-quart  size  or  thereabouts).  The  frame  holds  the 
bottles  erect,  and  prevents  cracking  of  the  enamel  of  the  vessel.  (4)  Add 
water  until  it  is  slightly  above  the  level  of  the  milk  in  the  bottles.  (5) 
Heat  over  the  fire  until  the  bubbles  begin  to  rise  and  break  on  the  surface. 
(6)  Remove  the  vessel  from  the  stove,  covering  the  whole  top  with  a  clean 
cloth,  and  allow  it  to  stand  so  covered  for  25  to  30  minutes.  (7)  Lift  out 
the  wire  frame  with  the  bottles  and  stand  it  to  cool  in  a  shallow  pan  of 
running  water,  or  place  immediately  in  the  ice-box.  (8)  Keep  the  milk  in 
the  ice-box  until  it  is  used. 

PLATE  COUNTS 
Plate  Counts. — Plate  counts  of  the  bacteria  in  a  given  bulk  of  milk, 
water,  etc.,  are  made  by  taking  a  given  amount  of  such  substances  (e.g., 
1  c.c,  G)  and  mixing  it  with  a  tube  of  melted  but  cooled  agar  and  then 
pouring  this  mixture  into  a  sterile  Petri  dish  ( Fig.  8 ) .  The  mixture 
hardens,  forming  a  layer  in  the  bottom  of  the  plate,  and  is  then  left  at  a 
favorable  temperature  to  allow  the  organisms  in  it  to  develop  into  colonies 
or  visible  masses.  After  two  (or  three)  days  the  colonies  are  counted,  and 
the  number  of  colonies  is  taken  as  an  indication  of  the  condition  of  the  milk, 
water,  etc.,  which  was  used.  (It  is  not  thought,  of  course,  that  all  of  the 
bacteria  present  will  find  the  temperature,  food,  etc..  favorable  to  growth.) 
When  the  substances  contain  large  numbers  of  bacteria,  one  cubic  centimeter 
would  contain  more  than  could  develop  on  a  single  plate.  It  is  the  common 
practice  to  use  dilutions  of  the  original  substances  in  such  cases,  adding  a 
given  unit,  such  as  1  c.c,  to  a  large  amount  of  sterile  water  (10  c.c,  100 
c.c.)  and  making  plates  of  a  small  amount  (e.g.,  1  c.c.)  of  this  dilution. 
In  testing  milk,  eggs,  etc.,  very  weak  dilutions  are  usually  necessary, 
e.g.,  a  thousandth  or  a  ten-thousandth  dilution.  When  dilutions  are  used 
the  numlier  actually  developing  on  the  plates  is  multiplied  by  the  dilution 
to  give  the  probable  number  of  bacteria  per  c.c. 


APPENDIX  397 

GARBAGE  DISPOSAL 

Present  Army  Methods  of  Disposal. — A  recent  letter  from  the  Con- 
servation and  Reclamation  Division  of  the  Army  states  that  "  all  garbage 
is  sold  by  the  government  to  the  highest  bidder.  Garbage  is  collected  in  the 
greater  number  of  camps  by  the  government  and  turned  over  to  contractor 
at  transfer  stations.  The  prices  on  contracts  vary  greatly,  but  all  bids  are 
made  on  four  distinct  classes  of  kitchen  garbage  as  follows:  [a)  bread; 
(6)  raw  and  cooked  meats,  and  fats  and  grease;  (c)  bones;  (d)  other 
garbage. 

••  In  some  instances,  contractors  render  all  of  the  garbage,  getting  all 
possible  grease  and  fats  therefrom,  while  in  other  instances  garbage  is 
put  through  what  is  known  as  a  fat-boiling  process,  which  renders  about 
50  per  cent,  of  the  fats.  The  garbage  is  then  fed  to  hogs.  In  some  camps, 
this  division  purchased  small  rendering  plants  and  at  the  present  time  has 
under   consideration   the   operation   of   a   large   number." 

Horse  manure  also  may  be  disposed  of  by  contract  for  fertilizer.  This 
year's  income  for  that  is  said  to  be  over  $250,000. 

Improved  incinerators  are  being  developed.  One  of  the  best  seems  to 
be  the  Williamson  multiple  shelf  incinerator.  It  is  very  simply  constructed 
and  needs  but  200  pounds  of  wood  to  start  it.  It  is  a  "  simple  rectangular 
chimney  four  and  one-half  by  six  feet  inside  diameter.  It  has  a  grate, 
and  above  this  grate  comes  a  series  of  six  iron  plates,  arranged  in  zigzac^ 
fashion  as  bafSe  plates."  It  is  worked  through  two  small  doors  opposite 
each  shelf.  The  shelves  are  loaded  to  a  depth  of  three  inches,  and  the 
contents  are  pushed  down  from  shelf  to  shelf,  and  finally  to  the  grate. 
If  "  enough  garbage  is  supplied  it  will  burn  indefinitely."  At  Camp 
FunstoQ  over  nine  tons  of  garbage  have  been  taken  care  of  in  twelve  hours. 
This  type  of  incinerator  seems  well  adapted  to  small  communities  as  well 
as   for  army  uses.        (See   also   p.    335.) 

TRAINING  FOR  PUBLIC  HEALTH   OFFICL^LS  AND   WORKERS 

Among  the  universities  which  have  already  established  correlated 
courses  in  public  health  work  are  Harvard,  Johns  Hopkins,  and  Yale.  These 
universities  offer  not  only  courses  covering  two  or  more  full  years,  but 
also  single,  short  courses  for  the  special  groups  of  health  officials,  e.g., 
industrial  inspectors. 

Additional  training  for  nurses  fitting  them  for  public  health  work 
may  be  secured  at  George  Peabody  College,  Nashville,  Tenn.;  School  of 
Civics  and  Philanthropy,  Chicago;  School  for  Social  Workers,  Richmond, 
Va. ;  Simmons  College,  Boston;  Teachers  College,  Columbia  University; 
and  Western  Reser\'e  College,  Cleveland,  Ohio. 

During  the  past  two  years  several  other  private  and  State  institutions 
have  offered  one  or  more  part-time  training  courses  in  such  work.  Those 
occupied  or  interested  can  secure  from  their  State  health  departments  addi- 
tional information  regarding  such  opportunities   for   preparatory  work. 


398 


APPENDIX 
TEMPERATURE  SCALES 


To  convert  degrees 
Fahrenheit  into 
degrees  Centigrade : 

r  subtract  32, 
i  multiply  by  5, 
I  divide  by  9 


196- 

lao- 

116- 

110- 

106- 
100- 


i 


-£B7 
-848 
-»9B 
-230 


-178 
-187 
-16B 

-145 
-140 


-113 
-104 


To  convert  degrees 
Centigrade  into 
degrees  Fahrenheit: 

(  multiply  by  9, 
•j  divide  by  5, 
I  add  32 


GENERAL  REFERENCES 

The  following  books  will  be  useful  as  references  for  practically  all  the 
chapters  of  this  book.  The  date  of  the  last  edition  is  given;  many  of  these 
books  have  frequent  new  editions  and  that  should  be  determined  before  a 
purchasing  list  is  decided  upon.  Extensive  lists  are  given  in  some  of  the 
General  Reference  books  listed  below,  especially  Eosenau.  No  attempt  is 
made  to  include  the  numerous  helpful  government  publications,  such  as  the 
publications  of  the  Bureau  of  Animal  Industry  on  milk  and  cheese.  For 
such  material  write  to  the  Superintendent  of  Documents,  Washington, 
D.  C,  for  such  lists  as  Price  List  51  on  Health,  Disease  and  Sanitation. 
Various  States  and  cities  have  important  publications,  such  as  the  Sanitary 
Code  of  New  York  City  and  of  New  York  State,  and  the  weekly  bulletins 
of  New  York  City  and  the  monthly  bulletins  of  New  York  State  and 
New  Jersey. 

BOOKS  ON  HYGIENE 
Bergey:  Principles  of  Hygiene.     Saunders,  Philadelphia,  1918, 
Harrington  and  Richardson:  Practical  Hygiene.    Lea  and  Febiger,  N.  Y., 

1914. 
Rosenau:  Preventive  Medicine  and  Hygiene.     Appletons,  N.  Y.,  1917. 
Sedgwick:  Principles  of  Sanitary  Science.     Macmillan,  N.  Y.,  1914. 
Wood:  Sanitation  Practically  Applied.    Wiley,  N.  Y.,  1917. 

POPULAR  READING  BOOKS 
Allen:  Civics  and  Health.     Ginu,  Boston,  1909. 
Chapin:      Sources  and  Modes   of  Infection.      Wiley,  N.  Y.,   1912. 
Chapin,  H.  D.:     Health  First.    Century,  N.  Y.,  1917. 
Gulick:  The  Efficient  Life.     Doubleday,  Page  Co.,  N.  Y.,  1907. 
Hill:  New  Public  Health.    Macmillan,  N.  Y.,  1916. 
Lee:  Health  and  Disease.     Little,  Brown  and  Co.,  Boston,  N.  Y. 
Winslow,  K.:  The  Prevention  of  Disease.     Saunders,  Philadelphia,  1916 

BOOKS  ON  BACTERIOLOGY 
Buchanan:  Household  Bacteriology.     Macmillan,  N.  Y.,  1913. 
Buchanan:  Veterinary  Bacteriology.     Saunders,  Philadelphia,  1916. 
Jordan:  General  Bacteriology.     Saunders,  Philadelphia,  1916. 
Kendall:    Bacteriology:    General,   Pathological   and   Intestinal.     Lea    and 

Febiger,  N.  Y.,  1916. 
Marshal:  Microbiology.     Blakiston,  Philadelphia,  1914. 
Moore:  Microbiology.     Macmillan,  N.  Y.,  1912. 
Park  and  Williams:  Pathogenic  Microorganisms.     Lea  and  Febiger,  N.  Y 

1917. 

399 


400  GENERAL  REFERENCES 

ADDITIONAL  CHAPTER  REFERENCES 

1.  Bacteria: 

Elementary  References: 

Conn:  Bacteria,  Yeasts  and  Molds.     Ginn,  1917. 
t  Morrey:    Fundamentals    of    Bacteriology.     Lea    and    Febiger, 

N.  Y.,  1917. 
Buchanan:   Household  Bacteriology.     Macmillan,  N.  Y.,  1913. 
More  advanced  references  are  given  under  the  general  references 
above. 
II.  The  Human  Mechanism  in  Relation  to  Health: 

Pyle:  Personal  Hygiene.     Saunders,  Philadelphia,  1917. 
Hough:  The  Human  Mechanism.     Ginn,  Boston,  1906. 
Stiles:  Human  Physiology.     Saunders,  Philadelphia,  1916. 

III.  Food: 

Beattie    and    Gould:    Commercial    Evaporation    and    Drying    of 
Fruits.     Farmer's  Bulletin   903,   1917. 

Edelmann :     Textbook  of  Meat  Hygiene.    Lea  and  Febiger,  N.  Y., 

1916. 
Fisher  and  Fisk:  How  to  Live.     Funk  and  Wagnalls,  1917. 
Fisk:    Alcohol.    Funk  and  Wagnalls,  N.  Y.,  1917. 
Jordan:  Food  Poisoning.     University  of  Chicago  Press,  Qiicago, 

1917. 
Lusk:    Food  in  War  Time.    Saunders,  Philadelphia,   1918. 
Order  211:  Meat  Inspection.     Bureau  of  Animal  Industry,  1914. 
Powell :   Successful  Canning  and  Preserving.     Lippincott,  Phila- 
delphia, 1917. 
Round  and  Lang:   Preservation  of  Vegetables  by  Fermentation 

and  Salting.     Farmer's  Bulletin  881,  1917. 
Rose:  Feeding  the  Family.     Macmillan,  N.  Y.,  1916. 
Service  and  Regulatory  Announcements.       Bureau  of  Chemistry, 

Washington   ( Concerning  adulteration,  etc. ) . 
Sherman:  Chemistry  of  Foods  and  Nutrition.  Macmillan,  N,  Y., 

1918;  Food  Products.    Macmillan,  N.  Y.,  1917. 
Vanderbilt   and   Vulte :     Food   Industries.      Chemical   Pub.   Co., 

Easton,  Pa.,  1912. 
Wiley:     Beverages.     Blakiston,   Philadelphia,   1918;    Foods  and 

Tlieir  Adulteration.     Blakiston,  Philadelphia,  1917. 
IV.  Milk: 

Klein:     Principles  and  Prax^tice  of  Milk  Hygiene.     Lippincott, 

Philadelphia,  1917. 
MacNutt:    Tlie  Modem  Milk  Problem.     Macmillan,  N.  Y.,  1917. 
Mendenhall:    IMilk.     No.   35.     Children's  Bureau.     U.   S.   Dept. 

Labor,  1918. 
Milk  and  Its  Relation  to  Public  Health.    Bull.  50,  Public  Health 

Service,  1909. 


GENERAL  REFERENCES  401 

Reports  of  the  Commission  on  Milk  Standards.  N.  Y.  Milk 
Committee,  N.  Y. 

Rosenau:  The  Milk  Question.  Houghton,  MifSin  and  Co.,  Bos- 
ton, 1912. 

Savage:  Milk  and  the  Public  Health.     Macmillan,  N.  Y.,  1912. 

Wing:  Milk  and  Milk  Products.     Macmillan,  N,  Y.,  1908. 

Stocking:    Manual  of  Milk  Products.    Macmillan,  1917. 

V.  Water: 

Hazen:   Clean  Water  and  How  to  Get  It.    Wiley,  N.  Y.,  1909. 

Hooker:    Chloride  of  Lime  in  Sanitation.    Wiley,  N.  Y.,  191.3. 

Mason:    Water  Supply.    Wiley,  N.  Y.,  1916. 

Turneaure  and  Russell :  Public  Water  Supplies.  Wiley,  X.Y.,  1913. 
VL  Air: 

Carpenter:  Heating  and  Ventilation  of  Buildings.  Wiley,  N.  Y., 
1915. 

Publications   of  the   New   York   State  Ventilation   Commission, 
N.  Y.  City. 
VII.  Sewage  Disposal  and  VIII.     Refuse  Disposal: 

Folwell:   Sewerage.     Wiley,  N.  Y.,  1916. 

Kennicutt,  Winslow  and  Pratt:  Sewage  Disposal.  Wiley,  N.  Y., 
1918. 

Morse:  The  Collection  and  Disposal  of  Municipal  Wastes.  Mu- 
nicipal Journal  and  Engineer,  West  39th  Street,  N.  Y.,  1908. 

Ogden  and  Cleveland:  Practical  Methods  of  Sewage  Disposal. 
Wiley,  N.  Y.,  1912. 

Parsons :  Disposal  of  Municipal  Refuse.     Wiley,  N.  Y.,  1906. 

Raikes:  Sewage  Disposal  Works.    Van  Nostrand,  N.  Y.,  1908. 

Venable:  Garbage  Crematories  in  America.     Wiley,  N.  Y.,  1906. 

Warren:  Sewage  Disposal  on  the  Farm.  Separate  712,  Dept. 
of  Agriculture,  1916. 

IX.  Transfer  of  Disease: 

Doane:    Insects  and  Disease.     Holt,  N.  Y.,  1910. 

Howard:  The  House  Fly.     F.  A.  Stokes,  N.  Y.,  1911. 

Reprint  43G.  Control  of  Communicable  Diseases.  Public  Health 
Service,  1918. 

Ross:  The  Reduction  of  Domestic  Flies.  Lippincott,  Philadel- 
phia, 1913. 

X.  Disinfection  and  Quarantine: 

Dakin    and   Dunham:    Handbook    of   Antiseptics.        Macmillan, 

1918. 
Dorset:    Some   Common   Disinfectants.     Farmer's   Bulletin   926, 

1918. 
Quarantine   Regulations   and   other   publications   by  the  Public 

Health  Service. 


402  GENERAL  REFERENCES 

XI.  Treatment  and  Prevention  of  Disease  and  XII.       Tests  for 
Disease: 

Bolduan:  Immune  Sera.     Wiley,  N.  Y.,  1914. 

Metchnikoff"  (Translated  by  Binnie  and  Ricketts)  :  Infection, 
Immunity  and  Serum  Therapy,  etc.  Amer.  Med.  Assn.,  Chi- 
cago,  1913. 

Thomas  and  Ivy:  Applied  Immunology.  Lippincott,  Philadel- 
phia, 1916. 

Zinsser:  Infection  and  Resistance.     Macmillan,  N.  Y.,  1914. 
XIII.  The  Home:  and  XIV.  Summer  Camps: 

Howard:  Preventive  and  Remedial  Work  against  Mosquitoes. 
Bull.  88,  Bureau  of  Entomology,  U.  S.  Dept.  of  Agriculture, 
1910. 

Keene:  Mechanics  of  the  Household.    McGraw-Hill,  N.  Y.,  1918. 

Ogden:  Rural  Hygiene.     Macmillan,  N.  Y.,  1911. 

Talbot:    House   Sanitation.     Whitcomb   and   Barrows,   Boston, 
1912. 
XV.  Schools: 

Andress:  Teaching  Hygiene  in  the  Qrades.  Houghton  Mifflin, 
Boston,  1918. 

Brown:  Health  Aspects  of  School  Lunches.  Reprint  26,  Health 
Dept.,  N.  Y.  City. 

Burks:     Health  and  the  School.    Appleton,  N.  Y.,  1913. 

Cornell:  Health  and  Medical  Inspection  of  School  Children. 
Davis  Company,  Philadelphia,  1912. 

Dresslar:     School  Hygiene.    Macmillan,  1913. 

Health  Essentials  for  Rural  School  Children.  Amer.  Med.  Assn., 
Dearborn  Street,  Chicago. 

Minimum  Health  Requirements  for  Rural  Schools.  Amer.  Med. 
Assn.,  Dearborn  Street,  Chicago. 

Rapeer  (Editor)  :     Educational  Hygiene.   Scribners,  N.  Y.,  1915. 

Terman:    The  Hygiene  of  School  Children.     Houghton  Mifflin, 
Boston,  1914. 
XVI.  Other  Community  Units  or  Relations: 

Pope:    The  Disinfection  of  Stables.   Farmer's  Bulletin  954,  1918. 

Schroeder  and  Southerland:  Laundries  and  the  Public  Health. 
Public  Health  Report    Reprint  385,  U.  S.  Public  Health  Ser- 
vice, 1917. 
XVII.  Infant  Welfare: 

Holt:  Diseases  of  Infancy  and  Childhood.  Macmillan,  N.  Y., 
1916. 

Publications  of  Children's  Bureau,  Washington.  (Include  con- 
tributions on  prenatal  care,  infant  care,  summaries  of  child 
welfare  laws,  surveys  of  conditions  in  different  localities,  etc. ) 


GENERAL  REFERENCES  403 

XVIII.  Tuberculosis: 

Huber:    Consumption.      Lippincott,   Philadelphia,    1906. 
Knopf:   Tuberculosis  a  Preventable  Disease,     Moffat,  Yard  and 

Co.,  1910. 
Moore:  Bovine  Tuberculosis.     Macmillan,  N.  Y.,  1913. 
Newsholme:  The  Prevention  of  Tuberculosis.     Methuen,  London, 
1908. 

XIX.  Industrial  and  Occupational  Diseases: 

Goldmark  and  Brandeis :  Fatigue  and  Efficiency.     Charities  Pub. 

Comm.,  105  East  22nd  Street,  N.  Y.,  1912. 
Kober  and  Hanson:  Diseases  of  Occupation  and  Vocational  Hy- 
giene.    Blakiston,  Philadelphia,  1916. 
Thompson:  The  Occupational  Diseases.     Appleton,  N.  Y. 
XX.  Mental  Hygiene: 

Bigelow:  Sex  Education.  Macmillan,  N.  Y.,  1916. 

Castle:      Heredity  in  Relation  to  Evolution,  etc.    N.  Y.,  1911. 

Conklin:    Heredity    and    Environment.      Princeton    University 

Press,  1916. 
Eastbrook:   The  Jukes  To-day.     Carnegie  Institution  of  Wash- 
ington, 1916. 
Goddard:  Feeblemindedness:  Its  Causes  and  Consequences.  Mac- 
millan, N.  Y.,  1914. 
Goddard:  Kallikak  Family.    Macmillan,  N.  Y.,  1914. 
Guyer:  Being  Well  Born.      Bobbs-MerrilL  Indianapolis,  1916. 
Guyer:  Being  Well  Born.     Indianapolis,  1916. 
Kellicott:    The   Social  Direction   of   Human   Evolution.     N.   Y.. 

1913. 
Metcalf:  Outlines  of  the  Theory  of  Organic  Evolution.     N.  Y., 

1904. 
Publications  of   the  National   Committee  for  Mental  Hygiene. 

Union  Square,  N.  Y. 
Thomson:  Heredity.     Putnam,  N.  Y.,  1913. 
Walter:  Genetics.     Macmillan,  N.  Y.,  1914. 
XXI.  Military  Hygiene: 

Keefer:  Military  Hygiene  and  Sanitation.     Saunders,  Philadel- 
phia, 1917. 
Manual  for  the  Medical  Department,  U.  S.  Army,  1916. 
Pryor:  Naval  Hygiene.     Blakiston,  Philadelphia,  1918. 
Wilson :  Field  Sanitation.     Geo.  Banta  Pub.  Co.,  Menasha,  Wis. 
XXII.  Vital  Statistics: 

Bailey:    Modern    Social   Conditions — A   Statistical   Study,   etc. 
1906. 
26 


404  GENERAL  REFERENCES 

Trask:  Vital  Statistics,  U.  S.  Public  Health  Service,  1914. 
Secrist:    An  Introduction   to   Statistical   Methods.     Macmillan, 
N.  Y.,  1917. 
XXIII.  Health  Education:  and  XXIV.  Health  Administration: 

Hemenway:   Legal  Principles  of  Public  Health  Administration. 
1914. 

Annual  Reports  and  other  publications  of  the  U.   S.   Public 
Health  Service,  Washington. 
Reports  of  the  U.  S.  Children's  Bureau,  Washington. 


INDEX 


Accidents 

alcohol,  36 

fatigue  relation,  315. 
Acid 

carbolic 

as    disinfectant,    188,    190 
as  standard,  191 
for  wounds,  202 

disinfectants,  188,  190,  202 

formed  bacteria,  6 

formation  milk,  64,  65,  88,  89 

soap,  192 
Acne,  211,  278 
Activated  sludge,   156,   157 
Adenoids,  relation  health,  265,  269, 

320,  322;  illustration,  266,  267 
Adulterants,  list  of  common,  34,  35 
Adulteration,  foods,  drugs,  33,  34,  35 

cheese,  34,  90 

chemical  tests,  40 

defined,  33. 

federal  decisions   and  reports   on, 
42 

food  and  drug  laws,  33 

foods,  table  of,  34,  35 

injurious  adulterants,   37,   38 

protection  against,  reasons  for,  37 

labels,   37 

meat,  43 

meat  regulations,  43,  45 

methods,   difficulties,   proving,   38- 
41 

microscopic  tests,   5 ; 

illustration  of,  39,  40 

milk,   70 

polariscope  tests,  41 

preservatives    in,    40,    41 

specific  gravity   tests,   41.   71 
Aerial  blanket,  120 
Agar,  bacterial  medium, 

plate,  10 
Age  changes    (see  Middle  Age) 


Agglutinins,  action  of,   196,   197 
disease  demonstrated  by,  213,  215 
negative  results  of  tests,  218. 
investigations   by   Bull,    197 
Air  (see  Humidity  and  Ventilation) 
bacteria  content,  115 

counts,   116 

determination  of,  116 

number  and  fate,   inspired  air, 
116 

persistence,  115,  116 

relation  altitude,  116 
dust,  fog,  lint,  116. 
water  surface,   116 

source  of,    115,   117 

types  of,  116,  117 

transfer  through,    116,    117 
carbon    dioxide     (see    Carbon    Di- 
oxide) 
carbon     monoxide      (see     Carbon 

Monoxide ) 
chemicals,     relation     soil,     water, 

127,   133 
composition  of,   127-134 

city   and   country,    128 
crowd  poisons,  134 
dust 

sources     and     relation     disease, 
135 

fog,  135 

house  problems,  135 

industrial  phases,  315,  316 
expired,     effect     taste,     appetite, 

135 
humidity    (see   Humidity) 
light  and  heat  relation,  135,  136 
night  air  and  disease,   169 
odors,      sources      and      avoidance, 

134,  135,  232 
oxygen  (see  Oxygen) 
physical   factors   most   important, 

il5 

406 


406 


INDEX 


Air,  breathed,  146,   147 

temperature,    relation    body     (see 
Temperature) 

types,  effects,   126,   127 

washed,    144 
Air      pressure       (see      Atmospheric 

Pressure) 
Air-borne  diseases,   116,   117,   169. 
Albany,     typhoid    rate     and     water 

supply,    110 
Alcohol,  as  adulterant,  36 

community  phases,  36,  37 

diseases   of   middle   age,   relation, 
300 

effect  on  death,  rate,  chart,  363 

feeble    mindedness    and    insanity, 
relation,  37,  320,  321 

food  value,  32,  36 

insurance     statistics,     36,     chart, 
363 

predisposition  to  disease,  36 

relation,    accident,    36 
hygiene,    36 

in  drugs,  37 

sold  as  medicine,  36 

wounds,  191 
Algae  in  water,  105 
Alum,  precipitation,   153 
Ammonia,  in  air,  134 
Anaphylaxis,  210 
Anaemia,  treatment,  211 
Anilme    dye,    for    colorless    poisons, 

191 
Anthrax,  action  of  lysins,  195. 

causal   organism,    hosts,   methods 

transfer,  179. 
Antibodies,  definition,  194 

formation  body  tissues,  209 

persistence    in   body,    200. 

response    bacterial    activity,    194, 
199,  200. 

stimulation      by      vaccines,      etc., 
203-206 

types,  table,   194 
Antitoxin   (see  Special  Diseases) 

action  of,   198 

anaphylaxis,  210 


Antitoxin,    description  and   produc- 
tion of,  206,  207 
mixed  with  toxin,  212,  table 
Appert,  canning  process,  54 
Argyrol,  189,   190 
Army,  United  States    (see  Military 

Hygiene ) 
Atmospheric  pressure  (see  Air) 
altitude  change  in,  137,  138 
body  adaptations,  variations,  137, 

13S 
decreased,   effects,    137 
effect  on  gases,  solution,   137 
effect   on   gases,    in   body   liquids, 

137-139 
effect  on   circulation,    137 
increased,  effects  of,   136-138 
relation    to    caisson    disease,    139, 
317 
Artesian  wells,  102,  103 
Auto-intoxication,    23 
Baby  welfare  exhibits,  372-374 
Bacilli,  2 

Bacillus  botulinus,  44. 
Bacillus  coli  food  poisoning,  44 
oysters,  49,  50 
presumptive   tests,   water,  97 
Bacillus  enteritidis,  44 

typhus,    3 
Bacteria,    action    of,    beneficial    and 
harmful,  6-9,   16 

oxidizing,  151,  156-159 
canning   spoilage    (see   Food   Pre- 
servation ) 
colonies,  11,  illustrations,  9,  10,  11 
counts   (see  Milk,  Water,  Air) 
cultivation  of,   changes  in  media, 
6,  7 

materials  used,  7,  10,  11 
culture,  pure,  11 
decay  brought  about  by,  8 
disease    (see  Special  Diseases) 
early     descriptions     and     investi- 
gators, 168 
effect  human  body,  9.  16 
entrance  body,  116,   117 

preferred  method,   174,   175 
exit  body,  173-175 


INDEX 


407 


Bacteria,  flagella,  illustration,  3 

food,  injury  to,  9   (see  also  Food) 

general    discussion,    1-11 

in  soil,  302 

in  ice,  96 

intermediate    hosts,    transmitted, 
177-179 

meaning  of  term,  1,  4 

microscopic  study,  illustration,  2 

motility,   1,  2 

due  to  flagella,  illustration,  3 

multiplication,   stages  of,  resting, 
9,  10 
vegetative,   10 

size,  2,  5 

spores,    9,    10,    56,    persistence    of 
spore  bearing,  115 

staining,  1 

structure,    4 

toxins   (see  Toxins) 

transfer   (see  Transfer  of  Disease) 

types  of,  2,  3 
Bacterin,   205 
Barber     shops,     disinfection     tools, 

towels,  etc,  277 
Bathing,  243 

shower,  243,  244,  263 
Bathroom,    care   and   equipment   of, 
241-243,  277 

heating  of,  243 
Bath  tub,  care  of    (see  House) 
Bedbug,   180,  248 
Bedroom,  bedding,  277 
Behring,  antitoxin,   199 
Bichloride  of  mercury,   192 
Binghamton,  typhoid  rate  and  water 

supply,  110 
Birth  registration 

certificate    standard     illustration, 
360 

compulsory,  361 

errors,   284,   360,   361 

methods  securing,  360 
Black  Hole  of  Calcutta,  134 
Bleach    (see  Hypochlorites) 
Bleaching    powder    (see   Hypochlor- 
ites) 
Blindness,  causes  of,  285,  286 


Blood  cells,  209 

counts,  138 
Boarding-house    (see  Restaurant) 
Bob  veal,  44 
Body,   human    (see   also   Food) 

effect  of  illness,  16,  299,  300. 

keeping  well,  16 

needs  of,  12-15 
Boils,  treatment,  206,  211 
Bone  marrow,  209 
Books,    disinfection    and    treatment, 

274 
Borax,    192 
Boric  acid,  189 
Boston,  period  water  storage,  105 

medical  inspection,  schools,  270 

water-carried  sewage,   151 
Buffalo,   relation  Niagara  Falls  ty- 
phoid, 104 
Bull,    investigation    of    agglutinins, 
197 

antitoxin  for  gas  bacillus,  345 
Butter 

adulteration,   34,   89 

disease-bearing,   90 

flavors,  89 

fuel  value,  20,  21 

pasteurized  milk  used,  89 

renovated,  90 

spoilage,  89 

■substitutes,    35 

starters,  89 

vitamines,  27,  90 
Caisson  disease,  causes,  139,  317 
nitrogen  in  tissues,  138,  139 
Calcium,  amount  in  body,  25 

essential  to  health,  27 

feeding,    disease,    27 

in  milk  (see  Milk) 
Calories,  bills  of  fare,  374 

definition  of,  19 

determination  of  (see  Glossary) 

food  classes,  20 

needs  per  day,  30,  33 

portions,  100-calories,  20 
Calorimeter    (Appendix) 


408 


INDEX 


Camden,  source  water,  94 

typhoid   rate,   94 
Camps   (see  Summer  Camps) 
Cancer,  causes,  300 
curable,  300,  301 
ftiiddle  age  and,  300 
prevalence,    300,   301 
Canning,  bacterial  changes,  10 
chemicals,   41,   54,   55 
cold  pack,  56 
containers,  57,  58 

methods,    discontinuous,    56 
pressure,   56,   57 
spoilage,   spores  responsible,   10 
Carbohydrates,  foods  rich  in,  21 
fuel  value,  20 
functions,  21,  22 
place  in  diet,  22 
storage,  22 
Carbon  dioxide,  blood  content,   130, 
131 
commercial  process,  effect  of,  130 
effect    on,  breathing  rate,  130,  132 
circulation  rate, 
health,  135 
in  air,  city  and  country,  128 
constancy,    128,    130 
content,    128,   130,    135 
expired  air,  130 

relation  plant  and  animal  life, 
128 
lung  exchange,  131 
relation  exercise  and  sleep,   131 
ventilation    standards    not    index, 
132 
Carbon  monixide,   poisonous   effects, 
132 

sources  of,   132,  230-232 
Carbolic  acid   (see  Acid) 
Carney,  rural  schools,  353 
Carrel-Dakin   treatment  of   wounds, 

343 
Carriers,    diphtheria,   176,   213,   256 
dysentery,  338 
human,  176,  177 
insect,   177-180 
meningitis,  176-180 
other  animals,  177 


Carriers,  paratyphoid,  338 

typhoid,  176,  177,  203,  213,  338 
Cell,  unit  of  structure,  4,  5 

blood-cells,  209 
Cellars  (see  House) 
Cemeteries,  menace  health,   102 
Certified  milk    (see  Milk) 
Cesspools    (see  Sewage) 
Channels  of  infection,  172 
Chapin,  transfer  of  disease,  169,  170 
Cheese,  adulteration,   34,  90 

disease,   relation,   91 

filled,  90 

food  poisoning,  90,  91 

pasteurized  milk,  used,  89,  91 

standards,  90 
Chemicals   (see  Food  Preservatives) 
Chicago,    hypochlorites,    stock    yard 

discharges,  109 

infant  mo'-tality  rates,  286 

source  water,  95 

typhoid  rate,  95 

water-carried  sewage,   15 
Chickenpox,   how  transferred,  isola- 
tion, symptoms,  chart  opp.  186 
Chickens,  bacterial  invasion,  50 

"drawn"  and  undrawn,  50 

preparation  for  killing,  50 

storage,  50 
Children's  Bureau,  campaign,  1918, 

295 
Children's  diseases,  symptoms.  111 
Child  welfare    (see  Infant  Welfare) 
Chlorides     (see    Hypochlorites) 
Chlorine,  water  treatment,  109 
Cholera,  diagnosis,  213,  215 

method  transfer,  174 

treatment,  211 

sanitation  as  protection,  212 
Churches,  ventilation,  273 
Cleaning  (see  House) 
Cleveland,  source  water,  95 

typhoid  rate,  95 
Clinics,  adult,  301 

infant,  293 

mothers,   287,  293 

rural,  352 

school  (see  Schools) 


INDEX 


409 


Cocci,  3 

Cohoes,    typhoid    rate    and    water 
supply,   110 
infant  mortality  rate,  291 
Cold,  cell  resistance  to,  10 
Colds,   common,   table  of   protecting 
substances,  212 
method  transfer,  174 
period  of  immunity,  200 
Cold  storage,  effect  meat  parasites, 
181 
foods,  50,  52-54 
temperatures,  52,  53 
time  limit's,  54 
Colonies    (see   Bacteria) 
Colostrum,  64 
Comfort  zone,  126 
Commercial  wastes    (see  Sewage) 
Communicable   diseases,   and   infant 
welfare,  294,  295 
chart  for  schools,  opp.  p.  186 
reporting  of,  181 
rules  for  avoiding,  181 
table  showing  method  transfer, 
173,  174 
Community  hygiene,  relations  of,  17 
barber  and  manicure  shops,  277 
dental  offices,   277 
hotels,  276 
laundries,  280 

library    and   school   books,    treat- 
ment and  disinfaction,  274 
moving  picture  halls,  274 
protection  of  food,  care  of  uten- 
sils, 275,  276 
restaurants,     ice    cream    parlors, 

etc.,  275,  276 
stores  and  markets,  280 
sunlight     in     churches,     libraries, 

273 
ventilation  main  problem,  273 
waiting-rooms,  278 
Conduction    (see  Heat) 
Constipation,  cause  of,  14 
food  relations,  24 
middle   age,   relation,   299 
natural  laxatives,  24 
predisposition  to  disease,  299 


Contact,  direct,   indirect,   168-170 

Contagious  diseases,   172 

Convection   (see  Heat) 

Cooling   devices,   ventilation,   145. 

Corrosive  sublimate,  90 

Cowpox,  204 

Croton   bugs,    247,   248 

Crowd  poisons,  134 

Deaths,  registration  area,  361 

Dental  offices,  appliances,  transfer 

of  disease,  277 
Deficiency  diseases,  26,  27,  28 
Delousing  stations,  340 
Department  of  Agriculture  food  and 
drugs,   regulations,   33 

foot-and-mouth  disease,  376 

meat    inspection    regulations,    43, 
45,  51 

score  card,  milk,  78 
Detroit,  source  water,  95 

typhoid  rate,  95 
Diabetes,  301 
Diet  and  health 

balanced,  28 

body  temperature,  121 

deficiency  diseases,  26-29 

exercise,  121 

mineral  lack  (see  Minerals) 
Dietary   requirements,   varying  age, 
weight,  body  surface,  etc.,  30 
standards,  30-32 
Diets,   balanced,   28   30 

infants    (see  Infant  Welfare) 

relation  middle  age,  298,  299 
Diarrhoea, 

bottle-fed  babies,  287 

flies,  relation  to,  289,  290 

relation  to  food,  292 
Diphtheria,     antitoxin     and     death 
rate,  208 

antitoxin  in  treatment,   198,   199, 
211 

horses  used  to  produce  serum,  207 

illustration,   7,  214 

prevention,  206,  207 

Schick  test,  217 

soap,  action,   193 


410 


INDEX 


Diphtheria,  susceptibility,  201 

symptoms,    isolation,    method    in- 
fection, chart  opp.  p.   186 

tolerance,   carriers,   213 

toxin  treatment,  207,  212 
Disease    (see  Special  Diseases) 

air  borne,  117 

after-effects  of,  299,  300 

army  figures,  338,  339 

body  reactions  to,  table,  194 

chemical   treatment,   202,   203 

communicable,   172 

contagious,  172 

control,  army    (see  Military  Hy- 
giene) 

control,  intermediate  hosts,  180 
environment,  180 
care  excreta,   180 
food,   180 

food  handlers,  182 
quarantine   and   isolation,    184- 
186 

how  to  avoid,  16 

iromunity,  following,  199,  200 
natural,  200 
other  types,  201 
passive,  209 
infectious,  172 

organisms,  exit  body,  172 
presence  demonstrated,  213 

personal  habits,  169,  170,  242,  276 

predisposing  factors,  201,  202 

tests  for  (see  Tests) 

transfer    ( see  Transfer  of  Disease ) 

treatment   and   prevention,    180 
chemical  agents,   180,  202,  203, 

209 
killed  organisms,  203,  205 
weakened  organisms,  203 
methods   of   attenuating  organ- 
isms, 204,  205 
dosage,  206 
table,  211 

tolerance  for  organisms,   213 

vaccination,    204,    205     (see   Vac- 
cine) 
Dish   washing    (see   House) 


Disinfectants,    cleansing    action    of, 
192 
emergency,   191 
high   coefficient,   191 
heat  as  aid  to,   192 
household,  danger,  attending  use, 

190,  191 
increase  efficiency,  192 
labeling  of,  191 
list  of,  189,  190 
patented,  191,  192 
poisonous  tablets,  191 
soaps,  192 
Disinfection    (see   Disinfectants) 
chemical,  188,  table  of,  189,  190 
concurrent,   187,  188 
discharges,  187,  188 
heat,  boiling,   189,   190 
human  waste    (Appendix) 
instruments,    slaughtering,    45 
room,  187,  188,  393,  394 
sewage  (see  Sewage) 
terminal,  187,   188 
theory  of,  187 
water  (see  Hypochlorites) 
wound  (see  Wounds) 
Dress,  relation     body     temperature 

and  cleanliness,  122,  123 
Dried  fruits,   chemicals,   59 

state  regulation,  61 
Drinking  cups,  individual,  278 
Drugs,  adulterations,  35 
food  and  drug  law,  33 
Dry  earth  pri\'y  (see  Sewage) 
Drying    (see   Food   Preservation) 
Dust   (see  Air) 
Dysentery 
carriers,  338 

causal  organisms,  44,  338 
method  transfer,  44,   174 
treatment,  211,  212 
Eggs,  bacteria  in,  50 
dried,  59 
storage,  61 
sulphur   in,   25 
white  of,  206 
Emlx)li,  gas;   caisson  disease,  139 
Energy  requirements    (see  Diets) 


INDEX 


411 


Engine    compared    human    mechan- 
ism, 12-16 
Excreta,    disinfection    and   disposal, 

187,  188,  336   (see  Sewage) 
Expectation   life   averages,   296 
Factory    conditions,    inspection,  etc. 

(see  Industrial  Diseases) 
Fall  River,  infant  mortality  rate, 

290 
Fatigue  and  efficiency,  15 

school  children,  263 

studies  of,  318 
Fats,  foods  rich  in,  20 

function,  body,  20 

effect  on  digestion,  20 

overfeeding,    21 

place  in  diet,  32 

relative  value,  other  foods,  20,  21 

storage,  21 

vitamines  in,  221  (see  Butter) 
Faucet,  safe  type,  278 
Federal  regulations 

food  and  drugs  33 

foot  and  mouth  disease,  376 

meat  inspection,  43,  45,  46 

quarantine,  181,  375,  376 
Feeblemindedness   (see  Mental 

Hygiene) 
Feet  (see  Military  Hygiene) 
Fermentation,   as   preservation   pro- 
cess, 59,  60 
Fermillac,  88 
Filter,  charcoal  used,  107. 

house  objections  to,   107 

sand,  102 

action  of,   106,   107 
construction,    illustration,    206 

self-cleaning,    107 

sewage  (see  Sewage) 

soil  as,  102 
Fish,  care  of,  as  food,  45,  46,  49 

cold   storage,   52,   53,    54 

decomposition   changes,   45 

poisoning,  49 
Fleas,    intermediate   hosts,    179 
Flies,  breeding  places,  garbage,   162 

camp,  251,  253 

campaigns,  280,  372 


Flies,  control  of,  162,  279,  280,  395 

disease  transfer,  68,  169,  170,  248 
(illustrations,   171,  252,  253) 

home, 

privies,  149 

stable  flies,  174 

stores  and  markets,  279,  280 

traps,  illustrations,  279 
Floor,    cleaning    (see  House,   clean- 
ing) 
Flour,  chemical  treatment,  34 

various  types,  26 
Fog, 

effect  throat,   135 

light  relation,  135 
Fomites,  172   (see  Special  Diseases) 

table,   173,  174 
Food, 

absorption  odors,  236 

acid  and   base  forming,   24 

adulteration,  33-35,  43 

amounts  needed,  28-30 

calorie  and  fuel  values,  19,  20 

canning,  methods,  55-58 

cold  storage,  52-54 
chickens,  49 
eggs,  61 
signs, 

cooking,  effects  of,  44,  50,  55 

diets   (see  Diets) 

functions  of,  18-33 

handlers,  46,  275 

laxatives,  natural,  24 

milk,  values,  62 

minerals  in,  25 

overeating,  29 

'poisoning,   43,   44,  74,  G 

preservatives,  chemical,  37,  41,  59, 
60,  61 

dried    fruits,   43 
injurious,  38 
natural  and  home,  59-61 

preservation,  methods  of,  51-61 

protective  coverings,  61,  279,  3.'!6 

regulations,  33 

sensitives,  28,  210,  212,  282 


412 


INDEX 


Food,  transfer  disease,    18,   43,  44, 
118,  182  (see  Special  Food  also) 

values  of, 

vegetables    as    food,    25 

vitamines    (see  Vitamines) 
Food  and  drug  laws,  33 
Food-and-mouth   disease,   causal   or- 
ganism, hosts,  method  of  trans- 
fer, 179 

federal  control,  376 
Formaldehyde   ( formalin ) , 

boats,  190 

flies,  280 

human  waste,  393 

room  disinfection,  189,  393 
Frozen  pipes  (see  House) 
Fruits,    dried,    chemicals,    59 

state   regulations,    61 

source,  minerals,  25,  26 
sugar,  22 
Fuel,  human  body  and  engine,  12 

values,  classes  of  food,  20 
Garbage   (see  Refuse  Disposal) 
Gas    bacillus,    antitoxin    as    protec- 
tion, 199 

antitoxin  from  horses,  207,  345 

illustration,  344 

treatment,  211 
Gas  gangrene    (see  Gas  Bacillus) 
Gas  masks,  342 
Gasoline,      emergency     disinfectant, 

191 
Glanders,  agglutinin  test,  198 
Goats,  milk,  for  babies,  288 
Gonorrhoea,  and  blindness,  285 

diagnosis,  213 

method  transfer,  173,  278 
Graham  flour,  26 
Green   plants,   relation  O,   CO2,   air, 

128 
Green  soap,  proportions,   192 
Hair    dressers,    care    towels,    appli- 
ances,  277 
Hay  fever,  theory  of,  212 
Health      administration,      advisory 
relations  of  Federal  department, 
375,  376 

co-operative  schemes,  379 


Health       administration,       diseases 
under  Federal  control,  376 
exclusion  of  aliens,  cargoes,  375 
interstate  control,  375 
local    departments,   cost   and   for- 
mation,  378,  380 
marine  service,  375,  376 
medical    inspection    of    employes, 

301 
Public  Health  Service, 
registration  area,  361 
regulation     of     serum,     vaccines, 

etc.,  375 
State  administration,  cost  of,  376 
powers,  duties,  376,  377 
relation,    local     departments, 
378 
surveys,    Carnegie    Corporation, 

374 
Child      Health      Organization, 
373 
Public  Health  Service,  376 
Health    education    and    methods    of 
advancing  campaign,  368-374 
exhibits,   material    for,    conduc- 
tion  of,   372-374 
Federal    Dept.    work,    373    (see 

Health  Administration) 
health  officers,  nurses,  etc.,  378- 

380  (see  Schools) 
historical,   366 
instruction,     schools,     colleges, 

etc.,  368,  372 
need  for,  366-368 
relation,  schools,  353,  368,  372 
surveys    (see    Health    Adminis- 
tration ) 
war  aids,  328,  369 
Health  officers    (see  Health  Admin- 
istration ) 
advisory,  379 
co-operative,   379 
salary,  advisable,  379,  380 
training  and  requirements,  378, 
380,  397 
Heat     (see    Temperature    and    also 
Ventilation ) 


INDEX 


413 


Heat,  conduction, 
body  loss,  120 
rate  air  and  other  substances, 

119 
relation  aerial  blanket,  120 
convection,  120 

elimination    body,    118-121,    rela- 
tion fat,  123 
loss,  human  body  wastes,  119 
evaporation,    119 
perspiration,    119 
radiation  and  conduction,   119 
production  human  body,  118    (see 

Oxidation ) 
radiation,   body   loss,    120 
contrast  convection,   120 
relation  ether,  120 
relation  clothing,  119,  122 
Heating     methods,     fireplaces     and 
Franklin  stoves,  231 
fuels,    230,    231 
hot  air,  228,  229 
hot  water,  229,  230 
jacketed  stove,  231 
moisture     relations      (see     Hu- 
midity) 
room  heaters  in,  230 
steam,   229,  230 
warmed  air,   229 
Home    (see  House) 
Hookworm,  illustration,   175 
method  transfer,  174 
preferred    channel   infection,    175, 

176 
route  in  body,  176 
Stiles,  southern  homes  and  school 
houses,  351,  352 
Horace    Mann,    introduction    study 

physiology  in   schools,   366 
Horse,  agglutination  glanders,  198 
Hospitals,    air    space    requirements, 
148 
ventilation,   cooling   systems,   145 
Hosts    (see  Insects  and  Transfer  of 
Disease) 
intermediate,  169,  170,  177-181 
Hotels    (see  Restaurants) 

bathing  and  toilet  appliances,  277 


Hotels,  bedding,  277 
food  liandling,  278 
personal   habits    attendants,   276 
sanitary  requirements,  276 
water  supply,  276 
House,    artificial   lighting,    225-228 
batliroom     care     and     equipment, 

241,  242 
cellars,  222-224 

cleaning,  methods  of,  244,  vacuimi 
cleaner,  245 

dish  cloths  and  towels,   246 

floors,    dishes,    245 

pans   and   kettles,   246 

personal  articles,  washing,  247 
disinfectants,  247,  393-396 
exposure     (see     Location,     under 

House ) 
filters    (see  Water) 
frozen   pipes,   237 
heating   (see  Heating  Methods) 
housing  laws,  220,  221 
ice-box,    235,   236 
insect  pests   (see  also  Flies),  247, 

395. 
kerosene,     for     toilet     seats     and 

floors,  243,  245 
kitchens,  233,  234 
legal        requirements,        animals, 

maintenance,  etc.,  221 
location,  soils,  221 

desirable    exposure,    224,    225 

course  of  sun,  illustration,  227 
pets,   household,   transferable   dis- 
ease, 248 
preparation  of  food   (see  Food) 
privies    (see  Sewage) 
plumbing,  236-241 
sinks,  234 

toilets,  care  of,  and  seats,  243 
transfer     of     disease,     242      (see 

Disease) 
traps    (see  Traps) 
ventilation   (see  Ventilation) 
waste-system,  238 
water-closet,  243,  illustrations, 

240-243 


414 


INDEX 


House,  water-coolers,  236 
water-system,  237,  238 
Human  mechanism,  comparison,  en- 
gine,  12-17 
bacterial  relation,  16 
effect  illness,  16,  299,  300 
fuel  needs,  12,   13 
oxygen,  13,  14. 

relation  to  environment,   16,  17 
repair,   15 
rest,  14,  15 

wastes,    14,   disinfection    (see  Ap- 
pendix) 
Humidity,  absolute,   124 
indoor   air,    124 
increasing,  126,  143 
outdoor  air,   124 
range  in  relative,  daily,   124 
relative,  124 

relation     to     body     temperature, 
125-127 
conduction,   125 
evaporation,  body,   125 
radiation,  125 
temperature,  air,   124 
room,  124 

devices,  control,  125 
limits,  124 
Hunger,    predisposition    to    disease, 

201 
Hydrogen  peroxide,  disinfectant,  190 
distribution  nature,   130 
effect,  air,  130 
wound  treatment,  189 
Hygiene 

community,    17 

instruction  public  school,  Federal 

support,  368 
personal,  17 
Hypochlorites   (see  Appendix) 
action  of,  108 

army  use,  334,  illustration,  335 
drinking  water,   108,   109 
home  use,  394 

swimming  pools,   109    (Appendix) 
Ice,  disease  due  to,  95,  96 
in  foods,  96,  97 


Ice,  manufacture  of,  96 

typhoid,  survival  in,  due  to,  96 
Ice-box,    care    and    temperature    of, 

235,  236 
Immune     bodies,     200      (see     Anti- 
bodies) 
Immune  period  disease  and  diagram, 

200 
Immunity  (see  Special  Diseases) 
active,  199,  209,  210 
age,   201 

light  or  missed  cases,  relation  to, 
.  200 

natural,  200 
tolerance,  confused,  201 
passive,  210 
persistence  of,  200, 
race,  201 
Incubation  period,  disease,  diagram, 
200 
isolation  during,  chart,  app.  p.. 
186 
Indigestion,  chronic,  milk  diets,  212 
Industrial    diseases,    accidents,    re- 
sponsibility for,  318 
death    rates    for      occupations, 

errors  in,  315 
effect  of  occupations    on  health, 

315 
factory,  conditions,  318 

inspection,  318 
and  efficiency,  15 
fatigue,  studies  of,  318 
insurance,   317 
legislation,    value   of,    315 
labor  attitude,  315-317 
predisposing  occupations,  table, 

316,  317 
table     of     objectionable     condi- 
tions, or  agents,  and  diseases, 
316,  317 
Infant  paralysis,  disinfection,  188 
method   transfer,    174 
method      infection,      symptoms, 

isolation,   chart  opp.   p.    186 
treatment,  blood  injected,  207 


INDEX 


415 


Infant   mortality    (see   Infant   Wel- 
fare) 
causes,    environmental    factors, 
287-291 
inheritance,    285 
midwives,    287 
decrease,  recent,  284,  285 
diarrhoea,  relation  flies,  289 
other  factors,  291 
diseases,  important,  291,  292 
rate,  291,  292 
temperature,   289,   290 
feeding,    bottle    and    breast    fed, 

287-288 
raw  and  pasteurized  milk,   table, 
84 
pre-natal   conditions,   287 

clinics   for,   287 
health,  mother's,  287 

legislation  afl'ecting,  286 
physical        care,        employment 
mothers,    289,    290;    illustra- 
tion, 290 
rates,    errors,   records,   284 
U.  S.,  284,  285,  290,  291 
foreign   countries,   284 
national  differences,  286 
relation  father's  earnings,  il- 
lustration,  291 
seasonal  differences,  290 
respiratory  diseases,  292 
Infant    welfare     (see    Infant    Mor- 
tality) 
care   bottles,    288 
Children's  Bureau,  work  of,  295 
clinics,     nurseries,     and     other 

aids,   293 
exhibits  and  literature,  372-374 
feeding 

milk,  care  and  preparation  of, 
288,  289 
goat's,   288 
overfeeding,  289 
water,    in    infants'    diet,    289 
milk  stations,   292,   293 
pre-school  periods, 

communicable  diseases,  294, 
295 


Infant   welfare,    pre-school   periods, 
feeding,  294 
sleep,  294 
preventable    defects,    p.    294     (see 
Schools ) 
research,  state,  293 
sleep,  294 

susceptibility    disease,    201,    il- 
lustration, 201. 
temperature,     relation     health, 
290 
Infection  channels  of,  172-176 

table,  173,  174 
Infectious  diseases,   172 
Infectious  jaundice,  341 
Influenza,  dosage,  vaccines,  206 

method  transfer,  174 
Insanity   (see  Mental  Hygiene) 
Insect  pests    (see  House) 
Insects, 

control    of    insect-borne    diseases, 

180 
hosts,  177-180,  251,  253    (see  also 
Transfer   of  Diseases) 
Intermediate   hosts    (see   Hosts) 
Intestinal  disorders,   in  middle  age, 

299 
Intestinal  disturbances,  milk  treat- 
ment, 212 
Intraspinal  injection,  210,  211. 
Intravenous  injection,  208,  209 

syringe  for,  209 
Iodine,  189 

Iron   salts,  precipitating  agent,   153 
Isolation       (see      Quarantine      and 
Schools ) 
communicable       diseases,       chart, 

children,   opp.   p.    186 
need  of  public  education,  186 
Ithaca,  typhoid  rate  and  water  sup- 
ply, 110 
Jacketed  stove,  259 
Jenner,    smallpox    immunity,    204 
Jersey  City,  source  water,  95 
typhoid  rate,  94,  95,  363 
Jesty,    smallpox    immunity,    204 
Kefir  grains,  88 


416 


INDEX 


Kerosene,    as    fuel,    230,    231,    for 

toilet  seats  and  floors,  243,  247 
Kidney  diseases,   relation  age,  298, 

301,    303 
Koumiss,  88 

Ladiawanna,  infant  mortality,  291 
Labels,  foods,  drugs,  37 
Laundries,   community,   282 

disease    transfer,    280-283 

municipal  or  community,  282 

municipal  control,  282 

processes,  effect  on  bacteria,  280, 
281 

sanitary  recommendations,  282 

types,  home,  steam,  etc.,  281,  282 

types   sprinklers,   including   blow- 
can,  282 

wet-washing,  283 

infant  mortality,  290 
Lawrence,  typhoid  epidemic,  104 
Lead  poisoning,  industrial,  315, -316 

water,  99 
Leaf   structure,   5 
Leprosy,  method  transfer,  174 
Libraries,    disinfection     and     treat- 
ment of  books,  274 

ventilation,  273 

window  area,  274 
Lice,  relation  disease,  179,  339-341 
Life  Extension  Institute,  301 
Life  insurance  tables,  relation   age, 

weight,  297,  298 
Lighting  (see  House,  also  Schools) 
Lime,    precipitating    agent,    sewage, 

153 
Lister,    treatment   wounds,    342 
Little  mothers,  293 
Lockport,  typhoid  rate  and  water 

supply,   110 
London,  sewage  disposal,  160 

water-carried    sewage,     151 
Longevity    tables,    relation    weight, 

298 
Lowell,   infant  mortality   r?te,   290, 

typhoid  epidemic,  104 
Lung  area,  209 
Lungs,    bacteria   breathed    in    daily, 

116 


Lusk,  balanced  diet,  28 

heat  production,  meat,  23 
Lye,  grease  in  traps,  240 
Lymph  nodes,  relation  to  centres  of 

infection,    9,    agglutinations,    197, 

209 
Lysins,  protection,  disease,  194,  195 

tests,  disease,  219 
Malaria,  causal  organism,  179 

methods   of   transfer,   180 

transmitted      by     intermediate 
host,  169,  177,  178 

treatment  by  drugs,  180,  203,  209 
Manicure,     appliances     transfer     of 

diseases,  277,  278 
Markets    (see  Stores) 
Matzoon,  88 
McClintock's  soap,  192 
Measles,  charts,  isolation  not  prac- 
ticed, 185 
isolation  practiced,  186 

introduced  into  Faroe  Islands,  212 

methods  of  transfer,  174 

susceptibility,  201 

symptoms,  186 
Meat,   adulteration,  43 

bob  veal,  44,  45 

diseases  transferred  by,  18,  43,  44, 
47,   177,   181 

horse,  43 

place  in  diet,  23,  24,  32 

value,  relation  other  proteins,  24 
Meat  inspection,  animals,  45 

bob  veal,  44,  45 

carcasses,  45,  46 

cold  storage,  45,  52-54 

effect  disease  organisms,   181 

completeness  of,  48 

Federal  regulations,  43,  45,  51 

foreign  conditions,  46,  47 

interstate   commerce,   46 

meat  foods  or  products,  43,  46 

municipal,  and  state,  48 

sanitary     regulations,     buildings, 
processes,  45,   46 

slaughter  methods,  48,  49 

storage,  45,  52-54 


INDEX 


iU 


Medical  inspection    (and  attention) 

adults,  301 

army   (see  Military  Hygiene) 

employees,  301 

rural,    352 

schools    ( see   Schools ) 
Medulla  oblongata,  respiratory  cen- 
tre,  etc.,   131 
Meningitis,  carriers,  detection,  quar- 
antine and  treatment,   176,  331 

diagnosis,    214,    215 

method  transfer,   174 

organism,    causing,    3 

treatment,  211 
Mental  defectives,    census     of,    323, 
324 

cost  of  supporting,  324 

immigrant  control,   324 

increase,    feeble-minded    in,    some 
States,  324 
in  U.  S.,  327 

Jukes   family,   326 

Kallikak  family,  326 

legal  control,  326 

legislation,  326,  327 

preventive  measures,  322,  327 

registration   of,   327 

training   of,   322 

treatment  of,  individual,  322,  323 

Zero  family,  326 
Mental  defects,  causes  of,  265,  320- 
322 

curable  forms,   322 

inherited,  325 

predisposition,   323 
types  of,  320 
Mental    hygiene,    National    Society, 

324,  373 
Metchnikoff,    milk,    88 

theory  white  corpuscles,    199 
Methylene,    blue,    or    colorless    poi- 
sons, 191 
Mice,  relation  disease,  234 
Micro-organisms,  types  and  actions 

of,  4,  8 
Middle  age,  cancer   (see  Cancer) 
constipation,  299 
diet,  relation  health,  298,  299 


Middle  age,  diseases,  23 

factors  predisposing  disease,  297 
height  and   weight  tables    29'(, 

298 
life  expectation,  296 
mortality,   relation  weight,  298 
physical  changes,   296,  297 
obesity,   297 

degenerative   diseases,   298, 
300 
examinations  and  results,  301 
Military  hygiene,  328-346 
bathing,  333 
clothing,  332,  333 
disease,  control, 
carriers,   338 
losses  due  to,  338,  339 

regulations       and       sanitary 
measures,    334-338 
diseases,  special 

infectious  jaundice,  341 
lockjaw,  344,  345 

nervous  disorders,  341 
trench    fever,   341 
foot,   341 
nephritis,   341 
tuberculosis,    302,    340,    341, 

345 
typhus,  339,  340 
defects  exempting  and  pliysical 

requirements,  329-331 
feet  care,  333 
shoes,  332 
food,  preparation,  rations,  336- 

338 
garbage  disposal,  167,  335,  336 
gas   bacillus,    illustration,   344 
causing  gangrene,  345 
treatment,  211 
gas,   poisonous,   341,   342 
navy  conditions  and  standards, 

345,   346 
rations,  336-338 
trench  conditions,  334,  335 
waste,  human,  disposal  of,  334, 
335,  illustration,  336' 


418 


INDEX 


Military    hygiene,    water,    care    and 

treatment  of,  333-335 

wounds  ( see  Wound  Treatment) 
army  packets,  343 
Milk,  adulteration,  34,  70,  71 
Babcock  tester,  72 
bacteria,  source  of,  67,  68,  76,  77 
bacterial   changes.   64-66 

content,   64,   72-77,   85 
calcium    in    25,    (see   pasteuriza- 
tion following) 
care  of,  cooling  after  milking,  77 

home,   70 

transit,   77 
certified   (and  other  terms) ,  85,  86 
colostrum,  64 
composition  of,   62 
condensed,  63,   87,   88 
cost  of  production,  86,  87 
counts,    bacterial,    77 

direct,  75,  76,  illustration,  75 
diseases,  diarrhoea,  84 

dysentery,   84 

carried  by,  65,  67,  77 

list  of,   65,   84 
dried,  59 

enzymes,  82,  illustration,  83 
epidemics    (see   diseases   above) 
fat  content,  62,  63,  tests  71,  72 
food  value,  20,  21,  62,  63 
grades,  84,  85 
gravity  tests,  71 
health  of  cows,  76 

of  workers,   66,   67,   85 
microscopic  examination,  73,  74 
milking    machines,    77 
milking  methods,  77 
minerals,  62 
North  system,  77 
odors,   source  of,   64 
pails,   care  of,  76,  77 

good  types,  illustration,  69 
pasteurization,   80 

advantages,  diet  infants,  84,  289 

changes     produced,     81-83,    il- 
lustration, 83 

commercial,  81 


Milk,   pasteurization,   effect  on  dis- 
ease organisms,  80 
enzymes,   82,  83 
health,   82 

extent  practiced.  80 

home,  82    (see  Appendix) 

methods,  81 

objections,  82,  84 

temperatures  used,  81 

tuberculosis,  81 
place  in  diet,  21,  23,  24,  30 
plate    count,    72,    396 
poisoning  due  to  milk  or  products, 

90 
prices,  relation  quality,  84,  86,  87 
products,  87,  butter,  89 

cheese,   90 
'  condensed  milk,   63,  87,   88 

fermented  milk,  88,  89 

powders,  87 

skim  milk,  63 
protein  in,  24,  value  of,  63 
refrigeration,  77 
score  cards,  78,  79 
solids,  62,  63 

methods  of  determining,  71 
standards,  accepted  bacterial,  76 

legal  (nutrients),  62,  63 

milk  commission,  85 

sanitary,  76,  80,  85 

types  of,  70 

variation  in,  63,  71 
sugar  in,  71 

temperature,  changes  in  milk,  82. 
83 

effect  on  tests,  71 

relation  bacteria,  68,  70 
tests,  Babcock,  72 

bacteriological,  72-76 

direct  count,  illustration,  74 

fat,  71 

methods,  71 

physical,  71,  72 

specific  gravity,  41,  71 

sanitary,  76,  80 
tuberculin,  tested,  77 
tuberculosis,  bovine,  67 

human,  67 


INDEX 


419 


Milk,  utensils,  sterilizing,  77,  illus- 
tration, 80 
vitamines,  27,  88 
Milk   powders    (see  Milk) 
Milk  products   (see  Milk) 
Milk  stations    (see  Infant  Welfare) 
Minerals,  balance,  25 
daily  requirements,  25 
essential  to  health,  25,  26 
foods  rich  in,  25,  26 
loss,  food  preparation,  26 
margin  of  safety,  proportion  body, 

25 
results  deficiency,  25 
water,  body  need,  25 
Minneapolis,  garbage  collection,  165 
Mississippi,  natural  purification,  104 
Molds,  classification  of,  4 

transmitted   intermediate  hosts, 
178 
Morbidity  records   (see  Vital  Statis- 
tics) 
Morons,  description,  320 
Mosquito,    malarial,    169     (see    Ma- 
laria) 
theories,  disease  transfer,  169 
yellow  fever,   169    (see  Yellow 
Fever ) 
Moving-picture  halls,  274 
Mumps,   isolation,  method  transfer, 

symptoms,  chart  opp.  p.  186 
Napkins,  covers  for,  283 
Naval    hygiene     (see    Military    Hy- 
giene 
Needles,    bacteriological    work,    11; 

illustration,  7 
Nervous  disorders  (see  Military,  also 

Mental  Hygiene) 
New   York    City   Board    of   Health, 
206,  301 
first  milk  stations,  293 
infant  mortality  rate,  284, 

291 
regulations,   bottled  water, 

113 
source  water,  95 
storage  water,  105 
typhoid   rates,  94.  95 

27 


Niagara   Falls,    epidemic,    smallpox, 
377 
tj^phoid  rate  and  water  supply, 
105,  110 
Nitrogen,  in  air,  proportion,  134 
relation  blood,  134,  138 

caisson  disease,  134,  138,  139,  table 
317 
Noise,  occupations,  317 
Nose,  sanitary  guide,  134,  135,  232 
Nutritional  diseases   (see  Deficiency 

Diseases) 
Obesity,    relation,    age    and    health, 

297,^298 
Occupational    diseases     (see    Indus- 
trial Diseases) 
Odors   (see  Air) 
Ogden,  rural  and  urban  conditions. 

347 
Ogdensburg,  typhoid  rate  and  water 

supply,   110 
Old  age,  food  needs,  30 
Oleomargarine,  34,  35 
Open-air  schools   (see  School) 
Opsonic  index,  tuberculosis,   196 
Opsonins,  aids  to  white  corpuscles, 

194,   195,  196 
Ophthalmia    neonatorum,    method 

transfer,    173 
Overeating   (see  Food) 
Overweight,  relation  length  life,  298 
Oxidation  (see  also  Respiration  and 
Sewage ) 

chemical  process,  127 

definition,  127 

source  body  heat,  118 
Oxygen,  air, 

content  and  constancy,  127-129 

amount,  minimum,  129 

blood  content,  129 

body  and  engine  need,  13 

city  and  country,  128 

daily  average,  129 

inspired   and  expire'     air,   128 

purifying  agent,  water,  104 

relation  plant  and  animal  life, 
127,  128 


420 


INDEX 


Oxygen,  room  content,  range,  129 

water  content,  104 
Oysters,  49 

bacterial  changes.  49 

decomposition,    signs,   45 

food     poisoning,     50      (see     Food 
poisoning) 
Ozone,  air,  amount,  129 
distribution,  29 

as  disinfectant, 
air,  129 

dressings,  etc.,  130 
water,  109,  130 

effects  on  man,  129 

sources,  130 
Paratyphoid,    food,    transferred,    44 

traced  to  milk,  65 

treatment,  211,  338 
Paris,  water-carried  sewage,  151 
Pasteur,  pasteurization,  80 

rabies,  205 
Park,  bovine  tuberculosis,   children, 

305 
Park  and  Williams,  pasteurized 

milk,  babies,  84 
Pasteurized  milk   (see  Milk) 
Peas,  copper  greening  of,  18 
Pellagra,  28 

Personal  hygiene,  problems  of,   17 
Perspiration,  amount  daily,  119 

temperature  relation,   119 
Pertussis   (see  Whooping  Cough) 
Petri  dish,  illustration,  7 
Plasma,  207 
Pets  (see  House) 

disease  transfer,  179,  181 
Phagocytes    (see  White  Corpuscles) 
Phagocytosis  (see  White  Corpuscles) 
Philadelphia,  source  water,  94 

typhoid  rate,  94 
Pickling  foods,  59,  60 
Piggeries,   167 
Pipette,  illustration,  7 
Pittsburgh,  source  Avater,  95 

typhoid  rates,  95,  303 
Plague,  causal  organism,  179 

sanitary  measures,  212 

transmitted  intermediate  host,  179 


Plague,  treatment,  211 
Plants,  structure  of,  4 
Plumbing,  236-241  (see  Traps) 
Poliomyelitis    (see    Infantile    Pa- 
ralysis ) 
Pneumonia,  method  transfer,  174 

treatment,  211 
Potassium,  overfeeding  of,  25 
Predisposition  to  disease,  diet  rela- 
tion  (see  Deficiency  Diseases, 
also  Food) 
hunger,  worry,  etc.,  201 
weight"  and  age,  297,  298 
Pre-school   period     (see  Infant  Wel- 
fare) 
Preservation  of  foods  (see  Foods) 
Pressure,  atmospheric,  136 

effect  on  gases  in  blood,  137 

increased  pressure,  138 
Presumptive  tests,  97,  98 
Privy   (see  Sewage) 
Problems,    33,   42,   51,   61,   91,    114, 

147,  161,   167,   182,  193,  212,  219, 

249,  254,  272,  283,  295,  314,  319, 

327,  346,  356,  364,  374,  380 
Protein   (see  Foods) 

uses  of,  daily  requirement,  22-24 

excess,  diet,  23 

food  poisoning  (see  Food  poison- 
ing, also  Special  Foods) 

foods  rich  in,  22,  24 

foreign,  210 

fuel  value,  heat  production,  20,  22, 
23 

liquefaction  of,  6 

loss,  food  preparation,  23 

milk,  fuel  value,  20 

protected,  22 

relation  cost,  diet,  22 

relation  to  disease,  23,  24,  298 

sensitives,  28   (see  Food) 
Protozoa,  meaning  of  term,  2 

cycle  in  development,  178 

illustrations,  4,  178 

pathogenic,  man,  4,  178 
other  animals,  4,  178 

transmitted,    intermediate    hosts, 
178 


INDEX 


421 


Protozoa,  types  of,  3,  4 
Providence,  source  water,  95 

typhoid  rate,  95 
Ptomaines    (see  Glossary  and  Food 

poisoning) 
Public   Health  Service    (see  Health 
Administration ) 
activities,  powers,  375,  376 
advisory  relations,  376 
historical,   375 
organization    chart,    opp.    p. 

376 
quarantine    regulations,    375, 

380 
reports  of,    376 
State  supervision  recommend- 
ed, 376 
Quarantine  ( see  Isolation ;  also  Dis- 
infection) 
boats,  cargo,  183,  184 
buildings,   183,  184 
diseases,  183,  375 
disinfection   (see  Disinfection) 
early  regulations,  183 
epidemic  control,   184,   186,  256 
Federal  control,  183,  375,  376 
house,  184,  185 
maritime,  183,  375 
meaning  of  term,  183 
methods,  184-187 
modified,  184 

public  attitude  concerning,  184 
school   regulations,   chart   opp.  p. 

186 
school  cards,  193 
ships,  183 
State  control,  183 
Quinine,  203,  209 
Eabies,  attenuated  organisms,  205 
causal  organism,  179 
hosts,  179 
treatment,  211 
Radiation   (see  Heat) 
Radium,  202 
Rats,  economic  loss,  180 

intermediate  hosts,   179,   180 
transfer  disease,  68,  234 


Red    corpuscles,    variation   altitude, 

138. 
Refuse,  army  disposal,   167,  335,  397 

average  amounts,  162 

classes  or  types  of,  162 

collection  of,  and  separation,  164 

disposal  methods,  163-167 

dumping,  163-165 

iij  control,  relation,  162 

garbage,  care  cans,   162,   163 
cleaning,    162 
fertilizer,  167 

incineration,   163-165,  167 

mosquito,   relation  to,    162 

piggeries,  167 

reclaimed  products,  167 

reduction,  process  and  plant,  165- 
167,  illustration,  166 

uses  of,  166,  16? 
Registration  ( see  Birth,  Death,  etc. ) 

area,  361 
Relapsing    fever,    causal    organism, 
179 
transmitted    intermediate    host, 
179 
Rensselaer,  infant  mortality  rate,  291 
Repair,  body  and  engine,  15 
Respiration      (see     also     Oxidation, 
Adjustment,  and  Compensatory 
Changes)    131,   132 

relation  of,  CO2,  130,  131 
Respiratory     diseases     and     infant 
mortality,   292 

and  ventilation,  261 
Restaurants,  276 

disease  carriers  in,  276 

drinking  water,  278 

finger  bowls,  278 

food  handling,  278 

napkins,  275,  276 

sanitary  requirements,  276 
Richmond,  inoculation  smallpox,  204 
Rose  cold,  theory  of,  212 
Rosenau,  infant  mortality,  290 
Rockefeller     Institute,     agglutinins 

tested,  198 
Rules  of  saving  and  safety,  32 


422 


INDEX 


Rural,    city    comparisons,    Crovvder, 
drafted  men,  350 
Ogden,  347 

city  and  country  boys,  356 
death-rate,  illustrations,  348,  349, 
J         354 

in  New  York  City,  347 
in  United  States,  1912,  350 
of  children,  city  and  country, 
350,  354 
defects,  physical,  350,  353 

chart,  354 
housing  conditions,,  rural  and  ur- 
ban compared,  350,  351 
medical  aid,  lack  of,  352 

compared  with  city,  352 
publications,   353 
sanitary  conditions,   351 
school  children,  in  rural  schools, 

352 
school  conditions,  census  of  75 
schools,  351 
chart,  355 

in  United  States,  353 
Stiles,  southern,  351 
Saliva  (see  Transfer  of  Disease) 
Salt,  as  disinfectant,  189,  192 
Salting  foods  (see  Food) 
Salvarsan,  203 
Sand  filters,  102 

San  Francisco,  laundry  control,  282 
Sanitary  codes.  Public  Health  Ser- 
vice, 376 
guides,   134 
Saving  and  safety  rules,  32 
Scarlet  fever,  method  of  transfer,  174 
disinfection,  187 
susceptibility,  201 
treatment,  211 
Schenectady,  typhoid  rate  and  water 

supply,  110 
Schick  test,  217 

School  children,  cleanliness,  263 
fatigue,  263 
feeding,  265 
health  reports  and  blanks,  268, 

269 
health   rules,  271 


School    children,    physical    defects, 
265-268 

medical  examination,  268 
Schools,  carriers,  256 
cleaning  methods,  263 
cloak  rooms,  263 
drinking  fountains,  256,  257 
epidemics,   256 
equipment,   hygienic  relations  of, 

256-258 
health  reports  and  blanks,  268,  269 
heating,  259,  260 
lighting,  258,  259 
location,  258 

medical  inspection  and  examina- 
tion children,  268,  270 
nurses,  268,  270 
open  air,  261 
prevention  of  disease,  255,  257 

illustration,  264 
relation   respiratory   disease,   261 
seating,  263 

teachers,  responsibility  for  health, 
255 
inspection  of,  270 
ventilation,  259-261 
Schroeder    and    Southerland,    laun- 
dries, 281 
Scouts,  girl  and  boy,  aids  campaigns, 

372 
Scurvy,  27 

Seattle,  civic  rivalry,  stimulus,  369 
Sensitives,  food  (see  Food) 
Septic  tank   (see  Sewage) 
Serum,  bactericidal  power  of,  199 
double,   purified   and  whole,    in 

treatment,  211 
horse,  198 
modified,  207,  208 
Sewage,  bacterial   action,   oxidation 
and  putrefaction,  151,  156-159 
broad  irrigation,  153,  154 
cesspool,  158 

bacterial  action,  157,  158 
illustrations,  157,  158 
leaching,  158 
water  tight,  158 
contact  bed,  159 
discharge,,  ocean,  lake,  river,  152 


INDEX 


423 


Sewag^e,  disinfection,  60 
disposal,  cost  of,  161 

important  processes,   151 
effect  on  soils,  153,  154,  222 
fertilizing  value,  154 

human  excreta  used,  vegetables, 
154-161 
flies,  149 

methods  of  treatment,  other,  151- 
154 
activated    sludge   tanks,    156, 

157 
before  disposal,  152 
bulk  reduction,  153 
cesspools,  158,  159 
contact  beds,  159 

filters,  bacterial  action,  156 
effluent,  155 
intermittent,   156 
structure,  154,  155 
trickling,  156,  illustration, 
Frontispiece 
screening,  sedimentation,  153 
chemical  precipitation,  153 
septic  tanks,   157 
sewage  farms,  153,  161 
subsurface  drainage,  154 
mineralization,  151 
natural  purification,   152 
per  capita  and  daily  averages,  153 
pollution  of  water,  effect  fish,  Hud- 
son River,  152 
putrefaction     (see    Bacterial    Ac- 
tion) 
relation  to  water  problem,  152 
soil  purification,  153,  154 
sludge,   153 

tanks,  156 
subsurface  drainage,  154 

illustration,  155 
systems,  compared  efficiency,  160 
dry  earth,  pail,  149,  151 
water-carriage,  cost,  150 
city  regulation,  151 
early  introduction,  151 
total  solids,  153 
trade  wastes,  160 
Sewer  gas,  public  mains,  133 
traps  and,  124 


Sheep,    179,  181 

Shellfish,  decomposition  changes  ( see 

Oysters ) 
Sherman,  fats,  21 

"  margin  of  safety,"  125 
cost  and  value  of  food,  31 
Shower  bath   (see  Bathing) 
Silver  nitrate,   189 
Siphon,  closet,  241 
Skin    (see   also   T'emperature,   Body 
Control ) 
thermal  regulator,  121-123,  141 
Sky  colors,  relation  air,  dust,  136 
Slaughter  houses   (see  Meat  Inspec- 
tion ) 
Slaughtering  animals  (see  Meat  In- 
spection ) 
Sleeping  hoods,   146;   illustration. 
Sleeping  porches,  146 
Sleeping  sickness,   causal  organism, 
179 
transmitted    intermediate   host, 
179 
Smallpox  and   cowpox,  disinfection, 
188 
early  methods  and  theories  of 

securing  immunity,   168 
inoculation   introduced.  Lady 
Montagu,  203 
adopted  in  U.  S.,  204 
Jenner,  204 

Jesty,  contribution,  20.4 
methods  of  attenuating  virus, 

203,   204 
table,  211 
transfer,  173 
vaccination,  204 
Soaps   (see  Disinfectants) 
Soil,  as  water  filter,  102 
bacteria  in,  102 
effect  of  sewage,  153,  154,  22'2 
Sauerkraut,  59 
Sour  milk  treatment,  212    (see  also 

Milk) 
Southerland,    Schroeder    and    laun- 
dries, 281 
diets,  87 
drinks,  88 


424 


INDEX 


Spleen,  209 

Spirilla,  4 

Spores,  9,  10,  56,  115,  190 

Staphylococcus,  206,  211,  212 

Starch,  formed  green  plants,  128 

fuel  valu-s,  20 

quarantine,   183 
State   health    departments    (see 

Health  Administration) 
Sterilization   (see  Bacteria,  Cultiva- 
tion of) 
Stiles,   hookworm,   southern   schools 

and  homes,  351,  352 
Stores,  animals,  domestic,  in,  279 

animal  pest,  279 

care  of  food,  279,  280 

cleanliness.  275,  277-2-80 

flies,  control,  279,  280 

refuse  disposal,  280 

sanitary  arrangements,  280 

scoring,  280 

stable,  location,  280 
Streets,  dust,  135 
Streptococci,  3,  73,  206,  214 
Subsurface  drainage  irrigation   (see 

Sewage ) 
Sugar,  cane  sugar,  fuel  value,  20 

fresh  fruit,  as  source,  22 

injurious    effects    of    overfeeding, 
22 

per  capita  consumption,  21,  22 
Summer  camps,  food,  251 
garbage  (see  Garbage) 
insect  pests,  251,  252 
toilets,  251 

waste  disposal,  250,  251 
water  drinking,  250;   collection 
of  rainwater,  251 
Sunlight,     bactericidal    action     dis- 
cussed, 101,  104,  172 

disinfectant,  188,  190 

water,  104 
Sweeping  and  dusting,  244,  245 
Swine,  transfer  of  disease,  44,  45,  47 
Syphilis,  inheritance,  284 

method  transfer,  173,  278 

treatment  by  drug,  203 


Syringe,  used  in  injection,  illustra- 
tion, 209 
Tacoma,  civic  rivalry,  stimulus,  369 
Tapeworm,  causal  organisms,  meth- 
ods of  transfer,  179,  180,  181 
Temperature    (see  Ventilation) 
high,  121,  122 
low,  120,  122 

atmosphere,  effect  constancy,   136 
body  adaptations,  117 
control,  dress,  122,  123,  127 
factors  aiding,   121,   123,   127 
regulatory  apparatus,  121, 
127 
normal,  117',  118 
Centigrade, Fahrenheit  (Appendix) 
comfort  zone,  126 
devices,  control,   125 
disinfecting    (see   Disinfection) 
predisposition  to  disease,  202 
relation  humidity,   125 
Toom,    variations    desirable,    123, 
141 
Tests     for     presence     disease      (see 
Special   Diseases) 
agglutination,  215 
carriers    (see  Carriers) 
diagnosis   by   isolation   of   organ- 
ism,  215 
antibodies  in  blood,  216 
difficulties  in,  217,  218 
material  for,  213,  214 
microscopic,  213-215 
Schick,  for  diphtheria,  217 
table  of,  218 

tuberculosis   (see  Tuberculosis) 
typhoid   (see  Typhoid) 
Wassermann,  218 
Widal,  216 
Tests   (see  Milk,  Water) 
Test    tubes     (see    Cultivation    Bac- 
teria) 
Tetanus  antitoxin,  199,  208 
immunity  of  chickens,  202 
method  of  transfer,  173,  175 
table  protecting  substances,  211 


INDEX 


425 


Tin,  in  foods,  41 
Tin-foil,  41 

Toilets,  care  seats    (see  House) 
paper  seats,  243 
summer  camps,  251 
types  of,  149-150,  240-242,  278 
Tools,  for  bacteriological  work;  steri- 
lization of,  11 
Toxin,  food  poisoning,  44 
accumulation  of,  202 
test,  Schick,  217 
treatment,    to    call    out   antibody, 

206 
table  of  protecting  substances,  212 
Trachoma,  method  of  transfer,  173 
Transfer   of  disease,   animals,   table 
of   diseases   contracted   from, 
179   (see  also  Hosts) 
air,  1G9,  172 
biological,   171 
carriers   (see  Carriers) 
channels   of  infection,    172-176 
contact,  direct  and  indirect,  168, 

170,  187,  188 
cross  transfer,  control  of,  187 
communicable  diseases  (see  Dis- 
ease) 
early  theories,  168 
fingers,  181 
flies  (see  Flies) 

fomites,    172    (see/  Special  Dis- 
eases ) 
food,  181,  182 
insects,    l69,    171    (see   also 

Hosts ) 
intermediate    hosts,     169,     I/O, 

177,  178,  179 
control  of,  180,  181 
personal  habits,   181 
rats    (see  Eats) 
saliva,  169,  170 
table  showing,   173.   174 
through  meat,  43-45,  47 
Transfusion  of  blood,  218 
Traps, 
bell,  239 

connection,  vent  pipe,  242    (illus- 
tration  showing) 


Traps,  double,  illustration,  242 
flies,  illustration,  279 
grease  in,  240 
S,  239 ;  illustration,  238 
string  in,  illustration,  240 
to  wash  out  and  wash  down  clos- 
ets, 240 
Trench,  fever,  341 
Trench  foot,  341 

Trichinosis,  hosts,  causal  organism, 
179,  181 
cases  and  deaths,  47 
Trichina    (see  Trichinella) 
Trichinella,   transfer  through  meat, 
47 
eff"ect  of  cold  storage,  181 
Trickling  fllter  (see  Sewage) 
Troy,  typhoid  rate  and  water  supply, 

110 
Turpentine,  191,  202 
Tuberculosis,  altitude,  309 
bovine,  47 

children  more  susceptible,  305 
importance  human  disease,  304, 

305 
method    transfer,    305     (see 

Transfer  Disease) 
prevalence  U.  S.  and  abroad,  306 
protective  measures,  306 
butter,  transfer  through,  90 
camps,  and  farm  colonies,  10,  310 
clinics,  dispensaries,  etc.,  310 
calcium  feeding  in,  26 
community   action   and   interests, 

310 
curable,  302,  310 
army,  340,  341 
death-rate,  decrease  in,  311 
foreign,  302 
relation   of  infant  mortality, 

284 
middle  age,  301 
U.   S.,   302 
diagnosis,  early,  302,  313 
economic  phases,  310-312 
food   important,  309 
goat's  milk,  freedom  from,  208 


426 


INDEX 


Tuberculosis,    Health    Xeics,     1914, 
typical  case,  310 
human, 

direct  contact  important,  307 

mortality  rates,  306 
■predisposing  factors,  307,  309 

relation  age,  307-309 
illustration,  304 
immunity,  adult,  307 
inherited,  313 
methods  transfer,   174,  303 

by  books,  274 

through  meat,  45,  47,  303 
Metchnikoff  on  phagocytosis,  199 
milk-borne,   303 
milk    supply    and    pasteurization, 

181 
national  committee  for  prevention, 

312 
opsonic  power  of  serum  measured, 

196 
preferred  channel  infection,  172 

chart,  173,   174 
prevention    infection,    rules,    308, 

309,  312,  313 

publications,   314 
pulmonary,  172' 
sites  of  infection,  302,  303 
sputum  (see  Prevention),  309,  312 
table  of  protecting  substances,  211 
tuberculin,   table   of    protecting 

substances,  211 

used  in  tests,  cattle,  306 
human,   307 

relative  value  of,  314 
types   of,   302 
water  supply,  303 
Turpentine,   191 
Typhoid,  agglutination  in,  196,  198 

illustration,  217 
carriers,  176,  177,  203,  213,  338 
cause  of  mental  defect,  321 
diagnosis    (Widal  test),  215.  21G 
dosage  of  vaccine,  206 
illustration,  216 
method  of  transfer,  173 
soap,  action,  193 
treatment,  211,  212 


Typhoid,  tolerance,  213 

transfer  through  food,  butter,  90 

lettuce,  235 

Typhus  fever,  causal  organism,  179 

transmitted   intermediate    host, 

louse,  179,  339,  341 

Ultra-violet  rays,  water   treatment, 

109 
Undereating,    or    underfeeding    (see 

Food) 
Underweight,  relation  life  averages, 

298 
Urban  (see  Rural) 
Vaccination,  212 
Vaccines,  autogenous,  206 

definition,  205 

dosage,  206 

dysentery,  211 

live  and  killed  organisms,  203-205 

mixed  and  pure,  211 

smallpox,  203,  204 

triple,  211 

typhoid,  211 
Vegetables,  as  food,  24 

cleaning  of,  235 

disease  transfer,  raw 

laxative  effects,  24 

minerals,  25,  26 

place  in  diet,  39 

source  protein,  24 
Ventilation    (see   Air,   Temperature, 
also  Humidity) 

aerial  blanket,  120 

building  materials,  through,  143 

churches,  273 

closed  window,  261 

cooling  devices,  145 

devices  to  avoid,  139,  146 

drafts,  139 

fireplace,  relation  ventilation,  148 
rate  replacement,  148 

floor  space,  145 

heat  lost  in,  232 

hospitals,  145 

illustrations,  140,  141,  142 

investigations,  115 

Londonderry  deaths,  148 

movies,  27'4 


INDEX 


427 


Ventilation,  natural,  142,  143 
navy,    conditions    and    standards, 

345 
New  York   State  Commission  on, 

126 
night,  233 

open  window,  142,  145,  146,  261 
public   halls    (see   Community 

Units) 
Jceplacement,  adequate,   139 
rates,  144 

relation  openings,  144 
requirements,  cubic  feet,  145,  148 

floor  space,  145 
sleeping  hoods,  146,  147 

porches,  146 
standards,  144,  273 
systems,  139-141 
through  building  materials,  143 
vents,  placing  of,  139 
washed  air  reheated,  144 
window,  140,  141.  145,  147 

relation     respiratory     diseases, 
142,  262 
Vent  pipes    (House) 
Vital  statistics,  aids  in  securing,  361 
basis  of  estimating,  358,  359 
birth    (see  Birth  Registration) 
birth  and  death  relations,  curve 

showing,  360 
collection  of,  360 
community  interest,  362-364 
details  used,  360 
errors,  361,  362 
marriage,  secured,  361 
methods    of    presenting    or    ex- 
pressing, 358-361 
methods  of  recording,  357 
morbidity  records,  357,  362;  ur- 
ban and  rural  compared,  350 
ocGupational,  363 
registration  area,  361 
standard  forms,  birth,  358 

death,  opp.  p.  360 
values   of,    to   community,    357, 
362,  364 
Vitamines,  animal  sources,  21 
disease  relationship,  27 


Vitamines,  lack  of  in  olive  oil,  28 
plant  sources,  27,  28 
temperature,  effects,  27 
types  of  and  value,  27 
V/aiters    (see  Hotels) 
Waiting-rooms, 

drinking  cups,  illustration,  278 
toilet  arrangements,  278,  279 
War,  relation  hygiene,  328,  329 
Washing,  of  clothes,  247 
Wassermann  test,  218 
Waste,  elimination  from  body,  14 
Waste  systems  (see  House  and  Sew- 
age) 
Water,  air  in 

amounts    needed,    leakage,    effect, 
111 
metered  supplies,  111 
minimum,    family,    etc.,    rates, 

110,  111 
variation,  causes.  111 
bacteria  in  various  types,  98,   102 
affected    by    low    temperatures, 
105 
bottled,  distilled,  112 
regulations,  113 
spring,  112,  113 
cistern,  99 

city  death-rates,  94,  95 
civic  needs,  111,  112 
classes  of,   93 
coolers   (see  House) 
cost,  111 

diseases  carried  by,  94,  95,  97' 
double  supply,  112 
epidemics,  95,  105 

Lowell  and  Lawrence,  104 
Niagara  Falls,  104 
examination  of,  98,  396 
family  rates.  111 
filtration,  106 
house  filters,  107,  236 
ground,  94,  102' 
hard 

causes,  effect  and  treatment,  99- 
101 
home  treatment  (see  Appendix) 
infected,  93 


428 


INDEX 


Water,  intestinal  bacteria,  97 
lead  in,  99 

Mills-Reincke  phenomenon,  95 
minerals,  25,  9y 

injurious  and  therapeutic,  101 
source  of,  94,  100,  101 
minimum  rates,  112 
natural   purifying   agents 
odors,  cause  and  removal,  105 
oxygen  in,  polluted,  152 
per  capita  needs,  110 
polluted,  93 
pure,  definition  of,  93 
relation  health,  95 

purification    of,    chemicals, 

108-110,  395 
dilution,  104 

filtration,   soil,   102    (see  Fil- 
ter) 
freezing,    96 
heat,   108 

home  methods,  107,  108 
natural  agents,  action  of,  103, 

104 
oxygen,  104 
sedimentation  and  storage, 

104,  105 
storage   105,  period  Boston 
and  New  York,  105 
rain,  99 
rates.  111,  112 
regulations, 

relation  to  general  health,  95 
role  in  body  and  other  uses,  92,  93 
sewage  pollution    (see  Sewage) 
soil  water,  100 
source  of,  body,  93 
storage,  eflfect  on  bacterial  count, 

99 
sunlight, 

surface  minerals  and  organic  mat- 
ter, 100,   101 
survival  of  bacteria,  104,  105 
tests, 

bacteriological,  chemical,  physi- 
cal, 97 
presumptive  tests,  97,  98 
relative  value  of,  98 


Water,  wells   (see  Wells) 
Water-carried  sewage   (see  Sewage) 
Water  closets   (see  House; 
Water  gas,  231 

Watervliet,  infant  death-rate,  2^1 
Wells,  artesian  or  bored,  102,  103 
illustrations,  good  and  poor,  100 
relation  area  drained,  103 
relation  soil  pollution  (cesspools) 
103 
subsurface  structure,  103 
White   corpuscles, 

action  of,  194,  195 

aided  by  agglutinins,  196-198 

by  opsonins,  196 
lung  cells,  similar  action,  110 
probable  relation  to  immune 
bodies,  209 
Whole  blood,  immunity,  211 
Whooping    cough,   method   transfer, 
174 
quarantine,  184 
susceptibility,  201 
table   of  protecting  substances, 

211 
transfer,  mode   infection,   isola- 
tion, chart  opp.  p.  186 
Widal  test,  216 
Winslow,  infant  welfare,  290 
Wood  alcohol,  and  blindness,  317 
Worry,  predisposition   to  disease, 

201 
Wound  treatment  (see  Military  Hy- 
giene) 
Carrel-Dakin  method,  343,  344 
chemicals, 

aniline  dyes,  203 
hypochlorites,  etc.,  343 
Lister's  contribution,  historical, 

342 
surgical  cleaning  of,  343 
Yeasts,  4,  8 

Yellow  fever,  causal  organism,  179 
methods  of  control,  180,  184 
sanitary  measures,  212 
susceptibility,  201 
transmitted    intermediate   host, 
169,  177-179 


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